1,1^^  SOUTHERN  REGIONAL  LIBRARY  c 


G000005  720     8 


i 


THE  •"^''6 


PHYSIOLOGICAL   FACTOR 


diag:rosi8. 


21   iDorh  for    lloung   |)cactitioners. 


BT 

J.  MILNER  FOTHERGILL,  M.D., 

PHYSICIAN     TO    THE     OITY     OF    LONDON     HOSPITAL     FOR    DISEASES     OF     THE 

CHEST    (VICTORIA    PARK), 

HON.    M.D.  RUSH    COLL.,  ILL., 

associate:   FELLOW   OF   THE    COLLEGE   OF   PHYSICIANS,  PHILADELPHIA. 


'  Skill  consists  of  a  foundation  of  common-sense  and  a  superstructure 
of  special  education.' 


NEW  YORK: 

WILLIAM    WOOD     &     COMPANY 

56  AND  58  Lafayette  Place. 

1883. 


\ 


Biomedical 
library 

AOO 


'  When  a  patient  places  confidence  in  a  member  of  the  profession, 
puts  his  life,  or  his  health,  the  prospects  of  himself,  and,  may  be 
those  also  of  his  wife  and  children,  in  his  hands,  the  least  he,  in  turn, 
can  do  is  to  meet  him  with  common  honesty.  If  he  be  not  entirely 
deserving  of  the  confidence  reposed  in  him,  let  him  try  to  be  worthy 
of  it  by  doing  his  best.  How  much,  however,  does  "  doing  his  best " 
involve  1  It  involves  all  that  lies  in  his  power ;  each  man  to  the  very 
best  of  his  ability.  "For  unto  whomsoever  much  is  given,  of  him  shall 
much  be  required."  "Doing  his  best"  is  taking  all  possible  pains, 
which  includes  such  information  as  may  be  attainable.  Avoidable 
ignorance  is  not  a  worthy  return  for  confidence.' 


624185 


MICHAEL  FOSTEE,   M.D.,  F.R.S. 

WHO    SO    WORTHILY    FILLS 

THE    CHAIR    OF   PHYSIOLOGY    AT    CAMBRIDGE, 

THIS  WORK 

BY 

THE     AUTHOR, 


PEEFACE. 


This  work  is  designed  for  young  practitioners  of  medicine 
entering  upon  private  practice. 

The  medical  student  is  apt  to  believe  that  medical 
education  interests  only  those  studying  medicine  and  those 
engaged  in  medical  tuition  ;  and  that  nothing  worth  the 
having  can  come  from  others  than  those  who  are  attached 
to  medical  schools.  This  impression  may  survive  the 
medical  curriculum ;  but  time  and  experience  dim  its 
outlines.  In  the  belief  that  the  present  work  supplies 
something  that  may  be  of  value  in  practice,  the  writer  lays  it 
before  the  young  practitioner,  for  his  verdict ;  not  without 
some  hope,  however,  that  he  may  find  it  useful. 

His  thanks  are  again  due  to  Dr.  D.  G.  Johnston  for  his 
aid  in  revising  the  proof-sheets. 

Ang.  1st,  1883. 
110,  Park  Street, 

Grosvenor  Square,  W. 


CONTENTS 


CHAPTER  PAGE 

I.    THE    HISTORY  (1)  OF    THE  FAMILY,  (2)  OF    THE   INDI- 
VIDUAL           -           - -  1 

II,   EXTERNAL  APPEARANCE    ------  7 

m.    THE   TONGUE      .-------  39 

IV.    THE  RESPIRATION -          -  55 

V.    THE   PULSE          --------  73 

VL  THE  ALIMENTARY  CANAL  -    -    -    -    -    -  101 

VII.  THE  URINE    --------  123 

VIIL    THE  REPRODUCTIVE  ORGANS       -          -           -           -          -  146 

IX.    THE  TEMPERATURE -           -  158 

X.   MOTOR  AND   SENSORY  DISORDERS       -           -           -           -  180 

XI.   THE   patient's    SENSATIONS         -----  203 

XII.    THE   PATIENT   IN   HIS   BEDROOM            _           .           -           -  239 

XIIL    CONCLUSION       --------  252 


THE 

PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


CHAPTER  I. 

THE   FAMILY  HISTOEY.        THE    HISTORY   OF  THE   INDIVIDUAL. 

When  a  patient  presents  himself  or  herself  before  the 
medical  man,  that  patient  is  commonly  a  stranger.  Every- 
thing then  has  to  be  learned  about  him,  as  well  as  about 
the  malady  for  which  the  medical  man  is  consulted. 

How,  then,  must  the  young  practitioner  commence  his 
examination  ?  Some  fly  at  the  patient  with  a  stethoscope, 
or  call  in  the  aid  of  divers  instruments  of  precision.  These 
latter  are  not  to  be  ignored,  certainly ;  but  there  is  much  to 
be  done  besides  resorting  to  these  valuable  aids.  Instruments 
of  precision  come  in  more  fittingly  at  the  close  of  the  exami- 
nation rather  than  at  the  beginning!  When  the  nature 
and  extent  of  the  patient's  disease  come  to  be  estimated, 
then  they  are  of  priceless  value.  How  they  are  to  be  used 
is  a  part  of  medical  teaching,  for  which  so  much  has  to  be, 
or  has  been,  paid ;  and  the  embryo  medical  man  is  sup- 
posed to  be  familiar  therewith.  But  much  precedes  resort 
to  these  aids. 

First,  it  is  desirable  to  know  something  about  the  indi- 
vidual. Private  patients  are  not  mere  social  units,  nor 
yet  numbered  entities  illustrating  this  or  that  form  of 
disease.  They  are  human  beings,  with  the  feelings  belong- 
ing thereto.      Life    is  sweet   to  all  :    and  there   are  few 

1 


2  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

patients  who  do  not  hold  themselves  as  valuable  lives, 
*  Mine  is  a  valuable  life,  doctor !'  is  the  remark  of  the 
breadwinner  of  the  family,  or  of  the  mother  of  numerous 
offspring,  or  maybe  of  a  social  waif  or  failure !  Conse- 
quently they  like  to  see  the  medical  man  approach  the  case 
with  interest,  and,  if  possible,  with  sympathy.  They  may 
not  be  able  to  form  a  fair  estimate  of  his  knowledge  ;  but 
some  opinion  of  him  they  will  bear  away  with  them.  It 
is  desirable  in  every  way  that  that  opinion  be  a  favourable 
one.  And  the  opinion  formed  will  greatly  depend  upon 
how  the  doctor  goes  about  his  examination.  He  may  soon 
demonstrate  his  familiarity  with  private  patients,  or  betray 
his  want  of  acquaintance  with  them ;  a  matter  the  patient 
will  soon  note,  or  that  friend  which  usually  accompanies 
the  patient  to  the  doctor  in  the  first  visit  will  certainly 
observe.  Two  brains  are  pitted  against  one.  While  the 
doctor  is  observing  the  patient,  the  onlooker  is  taking  the 
measure  of  the  doctor.  Young  practitioners  sometimes 
overlook  this  item.  Proceed,  then,  in  full  consciousness 
of  being  the  object  of  eager  scrutiny  !  It  is  your  duty  to 
the  patient  to  take  pains  :  it  is  your  duty  to  yourself  to 
make  it  perfectly  clear  that  you  are  taking  pains,  my  young 
professional  brother  !  Above  all  things  avoid  haste  in  your 
examination.  The  malady  is  of  deep  interest  to  the  patient, 
even  if  of  little  scientific  interest  to  you.  When  you  are 
known  to  be  a  busy  man,  patients  will  excuse  haste ;  but  at 
first  haste  is  looked  upon  as  indicative  of  lack  of  zeal. 
Proceed  systematically.  By  so  doing  you  will  not  be  so 
liable  to  overlook  some  important  matter,  which  may  escape 
recognition  otherwise. 

Place  the  patient  in  a  good  light,  so  as  to  give  the  eye 
every  advantage.  Observe  closely  while  putting  your  ques- 
tions. Do  not  hurry  the  patient.  Perhaps  the  latter  is  most 
eager  to  tell  you  something.  It  is  usually  well  to  let  him 
do  so.  Until  he  has  done  so,  his  mind  is  disturbed  and 
unequal  to  giving  such  answers  to  questions  as  are  desirable. 


INDIVIDUAL  HISTORY.  3 

If  not  to  tlie  point  altogether,  some  of  it  probably  is  worth 
noting.  The  first  thing  to  be  done,  after  putting  down 
the  patient^s  name,  is  to  inquire  his  age.  If  a  lady,  a 
little  tact  may  be  requisite  to  get  over  this  matter  without 
giving  some  offence.  This  matter  of  age  is  a  cardinal  fact. 
By  it  you  may  measure  almost  all  you  can  elicit.  But  of 
this  anon. 

The  Family  History.— Patients  attach  much  importance  to 
the  doctor  'knowing  their  constitution.'  With  a  stranger  all 
is  new.     How  are  you  to  learn  the  constitution  ? 

Inquire  first,  'Is  your  father  alive  ?'  If  so,  if  well.  If 
not,  what  does  he  suffer  from  ?  If  dead,  of  what  did  he 
die  ?     Ask  if  he   had  a  stroke,  or  dropsy,  or  fits,  or   was 

*  asthmatic  ' — this  covers  every  form  of  difficulty  of  breath- 
ing with  the  laity.  The  answer  will  often  give  you  a  clue 
to  the  malady  or  diathesis  of  your  patient.  Ask  if  there 
is  any  family  malady.  If  his  father's  brothers  and  sisters 
are  alive,  or  what  they  died  of.  If  there  is  any  family 
ailment,  by  this  you  will  learn  it.  If  the  patient  can  tell 
you  nothing,  the  probability  is  there  is  not  any  family 
ailment ;  and  this  negative  information  is  worth  the  trouble 
it  costs. 

Then  proceed  in  the  same  careful  manner  over  the  mother's 
side. 

Then  it  is  well  to  ask  the  patient  to  which  side  he  is  said 
'  to  take.'  Such  information  is  leading  up  to  the  next  matter 
viz.,  the  individual ;  and  will  usually  tell  whether  it  is  the 
nervous  system,  the  thoracic  organs,  or  the  abdominal  or 
pelvic  viscera,  which  first  fail. 

The  History  of  the  Individual. — It  is  well  next  to  proceed, 

*  Have  you  been  generally  healthy  ?  Were  you  a  strong 
child  ?  What  maladies  of  childhood  did  you  have  X  Out 
of  this,  much  that  is  useful  majj-  often  be  gleaned.  Of 
course  at  first  the  youthful  practitioner  gleans  but  little. 
As  his  self-education  progresses,  he  learns  more  and  more  by 
such  questioning. 

1—2 


4  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

It  is  well,  too,  to  inquire  as  to  growth  :  whether  the 
patient  grew  markedly  by  fits  and  starts.  A  long  growing 
fit,  by  which  a  great  addition  to  the  stature  was  attained, 
commonly  entails  some  mischief  in  one  or  other  lung  apex, 
of  which  distinct  evidence  may  remain.  All  apex  mischief 
is  not  recent,  when  found  by  the  doctor ! 

Puberty  occurs  during  the  period  of  growth,  and  few 
persons  escape  some  disorder  of  their  health  at  this  time. 
Especially  is  this  true  of  women.  And  now,  my  young 
reader,  permit  me  to  take  the  position  of  an  elder  brother 
for  a  moment.  For  am  I  not  your  elder  professional  brother? 
A  woman's  privacy  must  be  respected.  As  you  are  a  man, 
bear  that  in  mind.  Women,  too,  attach  even  an  exaggerated 
importance  to  matters  involving  their  reproductive  organs. 
But  before  a  class  of  students  it  is  very  difficult  to  make 
the  requisite  inquiries.  Consequently  as  a  rule  this  subject 
is  either  entirely  neglected,  or  slurred  over.  The  student's 
mind  is  not  roused  on  tbe  matter,  and  habitual  neglect  of 
the  subject  becomes  the  rule  in  life  ;  unless  the  practitioner 
is  awakened  to  the  matter  by  some  untoward  occurrence. 

The  time  when  the  catamenia  appeared  ;  their  amount, 
whether  great  or  small ;  the  absence  or  presence  of  leucor- 
rhoea,  in  the  intervals  of  the  periods — all  ought  to  be 
ascertained.  Anyone  who  attends  the  clinique  of  Dr.  John 
Williams,  of  University  College,  will  be  struck  by  the  scru- 
pulous care  he  displays  on  this  matter ;  and  impressed  by 
the  manner  in  which  he  shows  its  importance  when  he 
comes  to  the  after-history  of  the  patient.  When  a  woman 
becomes  a  patient,  it  is  impossible  to  omit  such  inquiry. 
*  A  woman  is  an  organism  around  a  uterus,'  a  physiologist 
once  remarked.  The  matter  of  her  '  generative  expenditure ' 
previous  to  impregnation  (as  well  as  afterwards)  is  then  not 
to  be  ignored :  nor  yet  inquired  after  in  an  ofiensive  manner. 

Maturity. — Then  comes  the  subject  of  adult  life.  The 
occupation,  the  habits,  if  active  and  sedentary,  outdoors  or 
indoors.      Note   any  ailments  the  patient  may  have  had. 


THE  FAMIL  V  HISTOR  V.  5 

whether  they  were  readily  recovered  from,  or  otherwise. 
(If  the  patient  has  always  recovered  slowly,  make  your 
prognosis,  and  take  your  therapeutic  measures  accordingly.) 
Then  learn  how  the  evenings  are  spent ;  this  is  far  from 
unimportant. 

Then  ask  as  to  matrimony.  If  a  woman,  when  ?  how 
many  children  she  has  had  ?  at  what  intervals  ?  did  she 
suffer  much  in  pregnancy,  or  in  her  confinements,  or  after 
them  ?  If  she  has  had  any  '  slips  '  ?  the  conventional  term 
for  abortions,  or  premature  confinements.  A  *  slip '  often 
deteriorates  the  health  very  pronouncedly.  A  considerable 
blood-loss,  or  a  heavy  discharge  after  the  confinement  or 
slip,  usually  leaves  its  mark  behind  for  a  long  time.  Note 
also  if  the  patient  made  a  slow  or  rapid  convalescence. 
Further,  if  she  suckled  all  or  any  of  her  children ;  and  if 
not,  why  ? 

Sometimes  all  this  can  be  readily  ascertained,  particularly 
when  the  patient  is  intelligent,  grasps  the  questions  readily, 
and  ansv/ers  them  quickly  and  accurately.  But  all  patients 
are  not  intelligent !  Sometimes  the  information  has  to  be 
extracted  by  close  and  severe  cross-examination.  Some 
patients  will  admit  nothing  until  they  can  catch  the  drift 
of  the  inquiry,  and  make  up  their  minds  how  much  they 
will  answer.  Such  patients  are  often  Scotch.  Then  others 
will  answer  before  they  have  had  time  to  fully  grasp  the 
questions.  Such  are  often  Irish.  Some  tell  too  much,  others 
too  little.     Both  are  troublesome,  and  occupy  much  time. 

Much,  too,  depends  upon  the  confidence  you  inspire.  Men 
will  not  give  it  to  you  unless  you  seem  to  deserve  it.  If  they 
cannot  trust  your  prudence,  of  course  they  withhold  it.  If 
they  give  you  it  as  your  examination  proceeds,  you  may 
legitimately  feel  that  you  are  producing  a  favourable  im- 
pression. As  to  women,  they  not  only  must  have  faith  in 
your  prudence,  but,  more,  they  must  feel  they  have  your 
sympathy,  else  they  are  dumb.  Modesty  restrains  them^ 
or  sometimes  prudishness  interferes ;   and  the  latter  in  a 


6  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

"woman  whose  conscience  tells  her  that  her  conduct  has 
not  always  been  above  suspicion,  is  often  very  provoking. 
No  woman,  too,  chaste  or  unchaste,  will  answer  questions 
put  to  her  which  do  not  take  their  origin  in  the  fulness  of 
knowledge.  Unless  you  can  let  a  woman  see  that  you  know 
perfectly  what  you  are  talking  about,  your  questions  are 
asked  in  vain.  It  is  not  in  the  nature  of  a  woman  to 
answer  readily  or  trutlifully  idle  questions  on  delicate 
matters;  their  raison  d'etre  must  be  apparent.  Once 
convince  a  woman  that  your  questions  have  a  valid 
foundation  for  them,  and  she  will  give  her  confidence 
without  reserve.  But  you  must  not  nip  her  growing 
confidence  in  the  bud  by  want  of  care  or  sympathy,  else 
the  spring  will  dry  up.  Do  not,  too,  make  it  more  difficult 
than  it  might  be  to  her  to  answer  by  any  hesitation ;  ask 
after  delicate  matters  as  you  do  after  her  appetite.  En- 
courage a  woman  to  answer  by  making  answering  easy  to 
her.  Do  not  wound  her  womanly  modesty  by  asking  your 
questions  coarsely  or  without  due  consideration  for  her  feel- 
ings.    If  3'ou  forget  these  matters,  your  patient  will  not ! 

Establish  a  good  understanding  betwixt  you  anjd  your 
patient.  Without  this  the  relations  are  overstrained,  and 
a  rupture  will  soon  occur.  Be  patient.  The  patient  may 
be  nervous  :  put  her  at  her  ease  by  kindly  courtesy.^  Elderly 
patients  entering  upon  degenerative  changes  are  generally 
stupid,  because  the  brain  is  failing.  Often  they  are  doing 
their  earnest  best,  and  yet  are  stupid.  Do  you  not  suppose 
that  they  may  be  conscious  of  their  waning  powers,  even 
as  Samson  felt  his  strength  going  from  him  when  Delilah 
shaved  his  locks  ?  And  the  feeling  is  trying  enough  with- 
out the  additional  pain  of  seeing  that  their  enfeeblement  is 
apparent  to  others.  If  the  patient  presents  evidence  of  any 
taxation  of  the  nervous  system,  note  it,  and  bear  with  him, 
or  her  accordingly.  The  matter  of  mental  phenomena, 
however,  will  be  discussed  further  on  in  Chapter  XI.,  for 
they  often  are  of  the  greatest  importance. 


CHAPTER  II. 

EXTERNAL   APPEARANCE. 

While  this  interrogatory  is  going  on,  the  brain  need  not  be 
solely  engaged  with  what  is  reaching  it  through  the  ear ;  the 
eye  should  be  busy  taking  notes. 

The  information  so  furnished  is  of  priceless  value.  But 
the  eye  can  only  see  what  it  carries  with  it  the  power  to 
see  !  If  untaught,  the  eye  observes  little;  when  trained,  it 
can  see  a  great  deal.  This  subject  has  attracted  the  atten- 
tion of  some  excellent  observers.  Prof  Laycock  taught  the 
importance  of  '  Physiognomical  Diagnosis,'  in  the  recogni- 
tion of  diatheses  and  cachexiae;  Marshall  Hall  wrote  an 
able  article  on  '  Symptomatology,'  in  the  '  Cycloptedia  of 
Practical  Medicine;'  Jonathan  Hutchinson's  remarks  on 
teeth,  especially  in  inherited  syphilis,  are  well  known ;  S. 
Wilks  has  written  on  'Temperaments,'  and  Dr.  Southey 
on  '  Diatheses.'  Prof.  Gairdner  contributes  an  excellent 
memoir  in  Finlayson's  '  Clinical  Manual  for  the  Study  of 
Medical  Cases ;'  Prof.  Austin  Flint  has  an  admirable  section 
in  his  '  Clinical  Medicine ;'  as  a  contribution  to  this  subject, 
I  have  written  *  Semeiology '  {Xrjixeiov — a  sign),  in  the  Stu- 
dents' Aids  Series.  The  subject  is  one  which  will  attract 
further  attention  as  the  importance  of  other  matters  than 
mere  physical  examination  dawns  more  distinctly  on  the 
medical  mind.  The  narrow  if  intense  view  of  which  the 
late  Prof.  J.  Hughes  Bennett  was  the  most  famous  British 
exponent,  still  dominates  the  minds  of  young  medicos  who 
tread  in  the  footsteps  of  the  German  School  with  great 
fidelity :  alike  those  who  have  studied  in  Germany  and 
Austria,  and  those  who  cop}'-  them  at  home. 


I 


8  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

The  following  remarks  must  not,  however,  be  regarded 
as  exhaustive  of  the  subject. 

General  Appearance. — The  eye  is  scanning  the  general 
appearance  of  the  patient  while  the  conversation  proceeds. 
The  apparent  age  is  compared  with  the  chronological  age, 
and  the  patient  is  noted  to  be  comparatively  young,  wearing 
well ;  or  looking  much  older  than  he  is.  It  marks  whether 
lie  wears  the  hue  of  health,  or  the  pallor  of  cachexia  ;  the 
venous  flush  of  taxation  of  the  right  side  of  the  heart,  is  often 
accompanied  by  a  certain  blurring  of  the  features.  There 
may  be  obesity,  or  more  commonly  the  wasting  of  phthisis, 
or  other  emaciating  malady.  The  rapid  or  laboured  respira- 
tion may  tell  of  impairment  of  the  thoracic  space,  or  emphy- 
sema, the  accessory  muscles  of  the  neck  playing  actively  on 
each  respiration.  Or  there  may  be  the  untied  shoe  and 
swollen  feet  of  dropsy,  or  the  slit  shoe  of  gout.  In  other 
cases  the  waistcoat  is  buttoned  wrongly,  or  askew ;  or  the 
trousers  left  unbuttoned,  and  perhaps  the  shoe  down  at 
heel,  in  brain  failure.  At  other  times  the  gaping  waistcoat 
or  unfastened  gown  tell  eloquentl}'-  of  ascites,  or  an  ovarian 
tumour.  When  the  head  and  shoulders  are  thrown  back- 
wards to  maintain  the  balance,  the  abdomen  is  seen  to  be 
protuberant ;   and  pregnancy  may  be  the  cause. 

The  general  appearance  will  tell  us,  indeed,  how  far  the 
patient  is  '  ill '  from  the  malad}' — broadly,  that  is.  Some- 
times the  features  wear  a  fixed  look  of  pain  in  organic 
disease  producing  persistent  suffering ;  or  there  is  the 
bowed-down  look  of  frontal  headache,  seen  in  the  bilious ; 
or  the  hectic  flush  on  the  cheekbone  tells  its  tale,  '  that 
consumption  has  already  hoisted  its  bloody  flag  of  no 
surrender  ;'*  or  '  carking  care '  may  have  written  its  sig- 
nature legibly  on  the  features.  The  patient  may  look 
despairing,  or  courageous — a  matter  of  which  it  is  well 
to  make  a  note. 

Diathesis. — The  diathesis,  or  inherited  constitution,  com- 

*  It  can  sometimes  be  induced  to  haul  down  its  flag. 


EXTERNAL  APPEARANCE.  9 

monly  betrays  itself  in  the  physique  ;  and  the  recognition 
of  the  diathesis  often  tells  most  weightily  upon  the  opinion 
formed  as  to  the  course  the  case  will  take  and  the  measures 
required.  Syphilis,  with  anything  approaching  proper  treat- 
ment, is  rarely  very  disturbing  to  a  person  of  well-marked 
gouty  diathesis,  or  other  person  with  good  bones  ;  while  it 
is  likely  to  work  havoc  in  a  feeble,  strumous  constitution, 
despite  all  care.  As  these  different  diatheses  are  important, 
it  may  be  well  to  give  them,  with  some  abbreviation,  from 
Prof.  Laycock's  'Observation  and  Research.'  (The  reader 
interested  in  this  subject  will  find  it  dealt  with  at  length  in 
a  series  of  lectures  published  by  the  late  Dr.  Laycock,  in  the 
Medical  Times  and  Gazette  for  1862,  first  half-year.) 

The  Gouty  or  Sanguine  Arthritic  Diathesis. — This  pre- 
sents the  following  features.  A  well-developed  osseous 
system,  firm  muscles,  an  erect  carriage,  with  a  generally 
robust  appearance;  the  nutrition  is  active,  the  digestion 
(usually)  good  ;  the  respiration  is  deep,  the  heart  large,  the 
skin  usually  florid ;  the  head  is  large,  with  a  massive  jaw, 
the  teeth  solidly  enamelled,  while  the  hair  is  thick  and 
strong,  not  falling  easily;  the  pulse  is  usually  firm  and 
steady,  while  the  blood-pressure  within  the  arteries  is  high. 
Such  persons  are  liable  to  diseases  of  the  vascular  system. 
The  heart  becomes  hypertrophied ;  the  distended  arteries 
undergo  atheromatous  change,  the  aortic  valves  become 
diseased,  and,  to  a  less  extent,  the  mitral  valves,  while  true 
apoplexy,  aneui'isra,  and  angina  pectoris  belong  to  the  full 
artery.  As  time  rolls  on,  the  hypertrophied  heart  undergoes 
a  fatty  necrosis  of  its  fibrill?e,  sometimes  ending  in  sudden 
death,  while  at  other  times  dropsy  closes  the  scene. 

A  common  blend  is  that  of  the  gouty  with  the  nervous 
diathesis,  to  be  given  a  little  further  on. 

The  Strumous  Diathesis. — This  has  an  imperfectly  deve- 
loped osseous  system  as  one  of  its  characteristics.  The  bones 
are  small,  the  shafts  slender,  and  the  epiphyses  enlarged; 
the  hand  is  often  unshapely  from  this  osseous  defect.     The 


lo  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

thorax  is  small  (probably  this  has  something  to  do  with 
their  liability  to  phthisis).  The  forehead  is  often  lofty  and 
prominent;  there  are  either  long,  silken  eyelashes,  or,  in 
worse  cases,  broken  eyelashes  maybe  with  ophthalmia  tarsi ; 
the  jaw  is  light,  with  teeth  crowded  or  carious.  There  is 
a  certain  fulness  of  the  lips  and  alse  nasi,  which  give  a 
piquant  look  to  strumous  'fairy'  children.  The  hair  is 
often  light  in  colour,  and  fine  or  thin.  The  eyebrows  are 
arched,  or  very  straight;  often  thick  and  well-marked  in 
persons  of  dark  complexion.  The  skin  is  often  moist  with 
an  acid  perspiration ;  while,  in  strumous  children,  crystals 
of  uric  acid  (rhombs)  are  frequently  to  be  found  in  the  urine 
on  standing  some  time.  Diseases  of  the  bones,  rickets,  hip- 
joint  disease,  and  spinal  curvature  are  common  in  childhood  ; 
or  there  is  a  large  lardaceous  liver,  or,  more  commonly, 
enlarged  mesenteric  glands.  The  glands  of  the  neck  are 
liable  to  be  enlarged  as  childhood  merges  into  puberty, 
and  consumption  (pulmonary)  is  often  then  set  up — the 
consumptive  taint,  indeed,  commonly  goes  with  the  strumous 
diathesis.  Defective  nutrition  is  a  marked  feature  in  many ; 
consequently  tubercle  in  all  its  forms  is  found  in  the  stru- 
mous, from  the  meningeal  form  common  in  childhood  (acute 
hydrocephalus),  to  the  pulmonary  phthisis  of  adult  life.  To 
maintain  the  nutrition  is  the  difficulty  with  persons  of  the 
strumous  diathesis.  All  cachexise  affect  such  persons  pro- 
foundly. Red-haired,  or  very  black,  strumous  individuals, 
when  the  subjects  of  phthisis  or  syphilis,  suffer  greatly — 
dying  with  the  first  and  being  severely  handled  by  the  latter. 
The  ordinary  hospital  out-patient  is  commonly  of  this  dia- 
thesis. It  may  be  blended  with  the  gouty,  or  with  the 
nervous  diathesis. 

TJie  Nervous  Diathesis. — This  belongs  to  sliMit  beings, 
who  are  also  free  from  ftit.  It  seems  on  the  increase  at 
the  present  time ;  viz.,  in  other  words,  we  are  moving  in 
the  direction  of  the  nervous  diathesis.  The  osseous  frame- 
work is  small,  but  perfectly  developed.     There  is  usually 


EXTERNAL  APPEARANCE.  ii 

a  high  forehead  with  a  well-vaulted  skull,  with  small 
well-cut  features,  and  an  active  eye.  The  nervous  system 
is  highly  developed,  and  these  slight  beings  are  stronger 
than  they  look.  They  carry  little  fat,  and  have  small 
abdominal  viscera.  Active  energetic  beings  they  are ; 
sometimes  benefactors  to  their  neighbourhood,  at  other 
times  social  nuisances.  The  small,  chattering,  monkey- 
like beings,  not  unfrequently  seen,  are  the  less  desirable 
section  of  this  folk.  They  rarely  take  alcohol,  but  enjoy 
tea.  They  are  the  leaders  of  popular  benevolent  movements. 
They  belong,  indeed,  to  the  Arab  type  mentally  and  physi- 
cally ;  while  the  gouty  resemble  their  Norse  ancestors  in 
character  and  physique. 

The  gouty  and  nervous  diatheses  are  often  found  blended 
together.  Then  the  form  of  gout  assumed  is  not  so  much 
articular  as  the  dyspeptic,  with  skin  affections  and  nervous 
phenomena.  Indeed,  the  nervous  diathesis  carries  with  it 
a  history  of  various  neuroses.  One  member  of  the  family 
will  be  the  subject  of  neuralgia,  another  have  epilepsy,  while 
a  third  is  a  dipsomaniac. 

The  Bilious  Diathesis. — This  comprises  the  dark  swarthy 
beings  of  our  social  fabric.  They  are  stained  with  bile, 
and  liable  to  biliary  disturbances.  When  the  bilious  and 
gouty  diatheses  are  blended,  then  the  resultant  product  is 
a  large  pei'son,  fairly  active,  and  a  steady  worker.  The 
bilious  and  nervous  blend  furnishes  a  small  active  being. 
Such  is  the  typically  bilious  lady — active  when  fairly  well, 
but  a  great  sufferer.  On  the  other  hand,  when  the  bilious 
is  commingled  with  the  lymphatic  diathesis,  a  compara- 
tively helpless  creature  is  the  result. 

The  Lymphatic  Diathesis. — This  is  the  antithesis  of  the 
nervous  diathesis.  Large,  listless,  lazy  persons  belong  to 
this  class;  mostly  always  below  par,  requiring  whipping  up 
with  good  food  and  alcohol.  The  bony  framework  is  large, 
but  the  muscles  are  small  and  soft.  They  are  usually  of 
pale  complexion.      Such  persons    bear   depressants   badly. 


12  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

They  are  never  well  in  relaxing  areas.  Women  of  this 
type  are  prone  to  heavy  catamenial  losses  with  leucorrhoea ; 
and  are  liable  to  flood  profusely  in  parturition. 

When  the  eye  has  learned  to  distinguish  the  features  of  a 
diathesis  with  its  blends,  it  can  often  gather  valuable  indi- 
cations therefrom.  For  the  diathesis  modifies  disease  often  j 
gives  it  certain  characters,  valuable  for  prognosis  and  treat- 
ment,— the  outcome  of  full  complete  diagnosis.  But  in  many 
instances  no  distinct  diathesis  is  discernible,  the  blending  is 
so  complete. 

The  following  observations  of  Sir  James  Paget's  apply 
largely  to  the  matter  of  diathesis.  He,  in  speaking  of 
blended  diseases,  says  :  '  We  should  look  out  for  indications 
of  the  existence  in  the  same  person  of  two  or  more  morbid 
conditions  or  dispositions  such  as  may  be  derived  from  both 
parents  or  several  ancestors.  For,  as  in  plants  and  animals 
there  are  hybrids  and  mongrels,  or  as  in  chemistry'-  many 
compounds  and  mixtures,  so  are  there  in  diseases.  We  see 
them  in  the  multiform  and  confused  varieties  of  what  we 
Lave  to  call  rheumatic  gout ;  in  gout  crossed  with  scrofula, 
and  syphilis  crossed  or  mingled  with  scrofula  or  gout.  It 
is  often  not  difficult  to  discern  some  of  these  combinations 
among  our  cases ;  and  I  know  few  things  in  practice  more 
useful  than  to  be  able,  even  in  some  instances,  to  adjust  our 
treatment  to  the  proportion  of  each  disease  in  the  compound. 
But  we  may  be  sure  that  there  is  much  more  to  be  learned 
in  this  direction ;  and  it  is  best  to  believe  that  we  rarely 
have  to  do  with  a  simple  and  unmixed  morbid  constitution. 
There  are  few  worse  habits  in  practice  than  that  of  com- 
monly saying  of  one  case,  "  It  is  all  gout ;"  and  of  another 
"  It  is  all  scrofula,"  or  "  all  syphilis."  We  might  as  well  say 
of  any  Englishman  that  he  is  all  Norman,  or  all  Anglo- 
Saxon,  or  all  Celt.  We  may,  indeed,  sometimes  see  persons 
who  appear  to  be  as  types  of  races  unchanged  in  many 
centuries,  but  in  practice  we  had  better  study  every  man 
as,  for   better  or  worse,  a   composite  of  many  ancestors.' 


\ 


EXTERNAL  APPEARANCE.  13 

This  is  a  pregnant  passage  well  worth  thinking  over  agaia 
and  again.  Sir  James  admits  that  the  Norman,  the  Anglo- 
Saxon,  and  the  Celt  have  their  characteristics,  which  can 
be  recognised  in  the  blend.  So  of  diathesis  :  usually  it  is 
possible  to  discern  the  leading  characteristic;  while  in  many- 
cases  the  type  is  not  pronounced.  Of  course,  where  no 
distinct  diathesis  is  present,  this  scrutin}'  gives  negative 
results  ;  but  when  such  is  present,  the  power  to  detect  it  is 
a  valuable  possession. 

Cacliexia, — While  the  term  '  diathesis '  is  used  to  signify 
the  inherited  constitution,  '  cachexia '  is  employed  to  denote 
an  acquired  condition.  Thus  the  leading  cachexise  are  those 
of  syphilis,  cancer,  malarial  poisoning,  mercurial  or  other 
poisoning,  and  gout.  In  all,  except  plethoric  gout,  there  is 
the  pallor  of  anaemia ;  for  these  poisons  strike  at  the  con- 
struction of  red  blood-corpuscles.  When  a  cachexia  is 
detected,  the  diagnosis  usually  carries  with  it  the  successful 
treatment,  except  in  cancer.  The  cachexia  here  may  help 
to  clear  the  diagnosis  of  cancer,  but  it  abolishes  the  last 
ray  of  hope  even  of  successful  removal;  for  it  tells  that  the 
cancer  is  not  local,  but  in  the  system,  and  that  it  cannot 
be  eradicated, 

A  cachexia  may  be  implanted  upon  a  diathesis,  like  a 
spire  upon  a  tower  as  seen  in  some  church-steeples.  Thus 
a  person  of  strumous  diathesis  may  acquire  syphilis  or  gout, 
or  a  gouty  person  may  be  the  subject  of  lead-poisoning ; 
and  as  Garrod  and  others  have  pointed  out,  gouty  persons 
are  exceedingly  susceptible  to  lead,  often  suffering  from  an 
amount  of  lead  which  has  no  ill  effects  upon  other  persons 
(the  non-gouty).  A  person  of  the  nervous  diathesis  may 
be  also  the  subject  of  malarial  poisoning ;  and  then  the 
remarks  of  Sir  James  Paget,  just  given,  apply  closely.  In 
an  angemia  linked  with  a  cachexia.,  the  specific  remedy  for 
the  poison  must  be  added  to  chalybeates  for  blood-formation 
or  red  corpuscle-building  to  go  on. 

These  observations  are  of  treble  value  in  the  numerous 


14  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

cases  ■where  there  are  no  particular  physical  signs  to  observe, 
"where  the  young  practitioner  is  apt  to  find  himself  utterly 
baffled,  and  left  helpless  by  his  medical  training  as  at  present 
conducted.  Malarial  or  paludal  poisoning  has  no  physical 
signs;  indeed,  furnishes  nothing  to  the  test-tube  or  the 
microscope — at  least  in  life,  and  only  doubtful  evidences 
after  death.  But  it  may  write  legibly  on  the  tegument  its 
name  and  lineage  :  not  always,  however,  in  such  bold  cha- 
racters that  he  that  runs  may  read ;  sometimes  in  such  small 
print  that  it  requires  a  keen  scrutiny  to  decipher  it. 

Yet  the  pallor  of  one  cachexia  differs  from  that  of  another. 
There  is  the  pallor  of  simple  anaemia  from  loss  of  blood,  or 
other  drain  ;  which  is  without  a  cachectic  shade.  In  gastric 
ulcer,  however,  there  is  often  perceptible  cachexia.  In  the 
large  white  kidney  there  is  usually  a  cachectic  pallor  which 
the  eye  learns  to  recognise — if  language  be  not  sufficiently 
precise  to  describe  it.  Sometimes  the  skin  has  a  hue  as  of 
discoloured  parchment^  which  I  have  observed  in  some  cases 
of  visceral  cirrhosis,  and  in  some  young  men  with  sj^philis. 
In  chlorosis  the  anaemia  has  a  greenish  tint.  Then  there 
is  a  waxy  pallor  in  profound  anaemia,  especially  in  per- 
nicious anaemia.  Or  there  may  be  a  colour  added,  as  in  the 
yellow  hue  of  cancer  and  the  bronzing  of  Addison's  disease. 
There  is  the  hue  of  the  gipsy,  which  has  been  mistaken  for 
Addison's  disease.  While  at  other  times  the  skin  looks 
muddy  and  opaque,  as  in  some  cases  of  syphilis,  and  in 
other  cases  of  grave  organic  disease.  The  mitral  flush  is 
often  marked  ;  while  the  deeplj'-  injected  face  of  some  cases 
of  distension  of  the  right  side  of  the  heart  is  itself  sufficient 
to  establish  the  nature  of  the  case.  The  '  blue  man  '  whose 
tissues  are  stained  by  a  long  course  of  nitrate  of  silver, 
usually  taken  for  epilepsy,  is  now  only  occasionally  seen. 

Expressions. — Beyond  the  hue,  there  are  matters  con- 
nected with  the  muscles  of  expression  which  are  worth 
noting.  The  face  of  cholera  is  ashen  in  hue,  the  skin  livid, 
the  eye  sunken,  for  the  water  of  the  tissues  is  being  drained 


\ 


EXTERNAL  APPEARANCE.  15 

away.  The  Hippocratic  face  of  death  is  pale,  of  a  leaden 
hue,  with  sunken  eyes,  the  eyelids  often  separated,  the 
cornea  losing  its  transparency  and  the  eye  its  expression ; 
the  nose  is  pinched,  the  temple  is  hollow,  and  lower  jaw 
drops.  This  is  the  face  of  the  dying,  and  when  well  marked 
tells  that  no  recovery  is  possible.  In  the  typhoid  state — 
whether  from  a  long  high  temperature  melting  down  the 
tissues,  or  from  a  more  truly  ursemic  condition — the  face 
is  dul],  vacant,  and  without  expression,  while  the  teeth  and 
lips  are  covered  with  sordes ;  when  advanced,  the  mouth  is 
open  and  the  tongue  is  seen  like  a  brown,  fissured  ball ; 
while  the  patient  lies  flat  on  his  back  in  bed,  slipping  away 
from  the  pillow  towards  the  foot  of  the  bed.  Whenever  a 
patient  who  has  been  flat  on  his  back  moves  over  to  one 
or  other  side,  this  is  of  good  omen.  In  pyaemia,  the  expres- 
sion is  lost  in  a  look  of  dull  indifference.  Then  there  is 
the  anxious  look  of  real  illness,  which  often  is  most  valuable 
in  helping  the  observer  to  read  aright  the  meaning  in  some 
very  complex  cases  where  it  is  impossible  to  say  whether 
the  case  is  a  serious  one  or  not,  without  such  aid.  On  the 
other  hand,  the  natural  expression  of  the  face  may  whisper 
hope  even  when  the  case  presents  some  very  dark  pheno- 
mena. It  is  in  their  subtle,  incommunicable  power  to  read 
the  facial  indications  that  some  practitioners  excel  so  in 
prognosis  :  they  can  give  no  explanation  beyond  '  You  can 
see  it  in  the  face  ;'  but  what  that  '  it '  is,  they  cannot  tell. 
Nevertheless  they  can  both  see  it  and  read  its  interpretation. 
The  face  of  true  organic  disease  entailing  much  suffering  is 
eloquent  in  many  cases.  There  is  a-  pallor  blended  with  a 
look  of  pain,  as  seen  in  abdominal  aneurism  eroding  the 
spinal  column,  or  intervertebral  cancer.  It  is  also  seen  in 
recurrent  paroxysms  of  angina  pectoris ;  and  is  often  pro- 
nounced in  cases  of  persistent,  racking  headache  of  organic 
origin.  Sometimes  this  bowed-down  look  of  pain  is  seen 
in  women  who  are  markedly  '  bilious.' 

In  some  acute  conditions  the  expression  is  very  suggestive. 


i6  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

The  reader  knows  this  who  has  watched  the  oncome  of  a 
labour-pain  in  a  parturient  woman.  It  is  a  certain  twitch 
of  the  lips  with  that  contraction  of  the  eyebrows  which 
produces  a  frown.  In  the  second  stage  of  labour,  this 
peculiar  look  passes  into  one  of  determination  as  the 
patient  puts  forth  expulsive  efforts.  Once  seen,  this 
twitch  of  abdominal  pain  is  ever  after  readily  recognis- 
able. In  many  affections  below  the  diaphragm  involving 
recurrent  paroxysms  of  acute  pain,  this  twitch  can  be  seen 
flitting  over  the  face.  In  peritonitis  the  upper  lip  is  raised 
so  as  to  expose  the  front  of  the  teeth  in  a  manner  which 
is  quite  unique. 

In  the  face  of  hectic  fever  there  is  the  wasting  of  the 
tissues  which  throws  the  cheek-bones  up  in  strong  relief, 
with  a  red  spot  over  each  of  them  which  tells  usually  of 
softening  tubercle.  In  cases  of  extensive  lung-disease  of 
the  phthisical  variety,  the  nostrils  often  quiver  in  a  very 
significant  manner. 

The  Hue  of  the  Skin. — Pallor  is  the  product  of  anaemia ; 
either  the  transient  blanching  of  fear  where  the  facial  vessels 
contract,  or  the  more  persistent  state  of  insufficiency  of 
arterial  blood.  It  belongs  to  the  cachexise  as  described 
above.  Then  it  may  be  linked  with  oedema.  This  is  well 
seen  in  acute  nephritis,  and  in  some  cases  of  large  white 
kidney.  In  the  last  there  is  often  an  unusual  smoothness 
of  the  skin,  like  a  bladder  of  lard.  In  many  cases  the  skin 
is  also  dry  and  unperspirable,  and  seamed  with  wrinkles 
in  old  persons.  In  some  phthisical  patients  there  is  pallor 
■with  an  unctuous  skin,  and  such  accompaniment,  in  my 
experience,  is  of  bad  omen.  In  certain  cases  of  aortic 
disease  in  comparatively  young  persons,  the  skin  seems  to 
undergo  a  species  of  fatty  degeneration,  being  greasy  and 
opaque. 

In  plethora  the  hue  of  the  skin  is  deepened.  It  is 
not  the  rosy  red  of  sundry  high-complexioned  persons 
where    the    epidermis    is    thin    and    the    crimson    blood 


EXTERNAL  APPEARANCE.  17 

shows  clearly ;  it  is  the  injected  hue  of  vascular  fulness, 
what  used  to  be  thought,  and  not  inaccurately,  to  indicate 
apoplexy. 

It  is  the  high  colour  of  old  Father  Christmas,  and  often 
tells  of  good  living.  Or  it  may  be  due  to  exposure ;  and 
the  deep  colour  of  the  face  of  well-nourished  engine-drivers 
is  worth  noting. 

It  differs  from  venous  fulness,  which  is  darker,  just  as 
venous  is  darker  than  arterial  blood.  It  is  the  dusky  hue 
often  seen  where  the  respiration  is  embarrassed.  Here  the 
lips  are  of  purple  hue,  resembling  the  lips  in  the  cyanosis 
of  congenital  heart-imperfection.  Sometimes  deep-coloured 
crimson  dendritic  twigs  of  vessels  are  seen  at  the  alee  of  the 
nose  on  a  complexion  of  dusky  pallor,  telling  of  atheroma. 
Cyanosis  in  infants  and  young  persons  tells  of  reptilian 
hearts;  and  such  beings  rarely  survive  the  period  of  puberty, 
while  they  never  undergo  pubertal  changes.  A  peculiar 
blueness  is  seen  mostly  on  the  tip  of  the  nose,  the  lips 
■and  cheek-bones,  and  in  the  hands,  in  some  persons  who 
take  chloral.  It  is  a  hue  stti  generis,  in  my  experience  at 
once  unique  and  pathognomonic.  The  hue  of  venous  fulness 
is  worth  learning,  as  it  often  furnishes  most  useful  indica- 
tions.  As  a  transient  condition  it  is  often  suggestive  of  the 
patient's  condition.  When  seen  with  some  blurring  of  the 
outlines  of  the  face  in  cases  of  want  of  tone,  it  tells  the 
patient  is  not  so  well;  and  enables  the  shrewd  and  observant 
practitioner  to  say  to  the  patient  confidently,  '  You  are  not 
so  well  to-day !'  Or  its  absence  prompts  the  opposite 
remark,  'Ah,  you  are  feeling  better  to-day!'  (Both  of 
which  matters  are  worth  the  noting ;  for  by  the  remark 
made  the  patient  recognises  that  the  doctor  knows  what 
he  is  about,  or  the  opposite.)  Such  injection,  with  blurring, 
is  common  with  women  about  the  change  of  life ;  and  is 
almost  certainly  present,  more  or  less  frequently,  in  those 
cases  where  the  patient  is  subject  to  *  flushes,'  that  is,  rushes 
of  arterial  blood  to  the  head  and  neck.     It  shows  a  low 

2 


l8  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

arterial  tension  with  a  certain  amount  of  vaso-niotor  paresis, 
to  use  an  expression  in  vogue  at  present. 

A  flushing  of  one  cheek  is  common  in  pneumonia ;  usually 
the  cheek  of  the  affected  side.  The  establishment  of  such  a 
flush  is  significant  of  phthisis  in  chronic  pulmonary  disease. 

Then  there  is  the  red  tip  of  the  nose  of  dyspeptic  females 
with  constipation  ;  which,  as  a  chronic  condition,  contrasts 
with  the  transient  flush  across  the  nose,  extending  halfway 
over  the  cheeks,  significant  of  acute  indigestion  in  other 
ladies. 

All  these  associated  facial  conditions  are  worth  the  time 
it  takes  to  study  them.  The  information  so  furnished  to 
the  eye  will  often  guide  the  inquiries  and  inspire  the 
remarks  so  as  to  win,  and  deservedly  too,  the  confidence 
of  the  patient  and  the  patient's  friends.  These  last  are 
always  impressed  by  remarks  and  questions  which  tell  of 
the  doctor's  familiarity  with  the  patient's  malady  :  a  matter 
which  invites  their  confidence_,  and  not  in  vain. 

Then  there  are  items  in  different  portions  of  the  visible 
body  which  also  are  well  worth  the  noting.  To  proceed 
from  above  downwards,  the  first  m.atter  is  : 

The  Hair. — Strong  coarse  hair  does  not  fall  early,  said 
Professor  Laycock ;  all  such  hair,  he  holds,  belongs  to 
the  gouty  diathesis.  Certain  it  is  that  such  hair,  gcing  grey 
early,  is  found  in  comparatively  young  persons  of  robust 
physique  and  belonging  to  gouty  families.  It  remains  in 
advanced  life  white  as  driven  snow.  Good  hair  in  abun- 
dance is  usually  indicative  of  a  sound  constitution ;  though 
it  must  be  admitted  that  some  undoubtedly  strumous  indi- 
viduals, men  as  well  as  girls,  have  magnificent  heads  of  hair. 
Hair  turns  grey  in  two  ways  :  either  on  the  temples 
first,  spreading  from  thence  gradually ;  or  uniformly.  Some- 
times the  greyness  is  rapid,  indicating  some  great  trouble ; 
or  even  sudden,  in  intense  emotion.  At  other  times  an 
isolated  white  hair  is  seen  here  and  there  amidst  dark  or 
raven-black  locks.      This   is   like   the   solitary  snow-flake 


EXTERNAL  APPEARANCE.  19 

borne  on  a  northern  blast  which  precedes  the  coming  snow- 
storm !  it,  too,  tells  of  coming  whiteness. 

Some  observations  made  in  the  dead-house  of  the  great 
hospital  of  Vienna  told  that  such  isolated  white  hairs  in 
otherwise  dark  hair,  are  in  some  way  associated  with  kidney- 
changeSjfor  such  change  was  usually  found  therewith;  though 
these  were  not  necessarily  so  advanced  as  to  be  a  factor  in 
the  production  of  death. 

The  condition  of  the  hair  will  often  give  useful  informa- 
tion. Sudden  greyness  will  tell  of  trouble ;  or  if  at  the 
temple  onlj^  maybe  of  severe  f^icial  neuralgia.  When  the 
hair  is  seen  to  turn  much  darker  again,  then  it  tells  the  trial 
has  been  passed.  When  the  hair  is  glossy  and  bright,  it 
tells  of  good  assimilation  and  nutrition.  In  cases  of 
phthisis,  where  fat  is  not  taken  well,  the  hair  commonly 
loses  its  lustre,  becoming  dry  and  brittle.  If  the  case 
takes  a  turn  for  the  better,  the  hair  will  recover  its  natural 
appearance  as  a  return  to  health  is  achieved.  This  may 
be  so  marked  in  some  cases,  that  if  not  seen  for  a  consider- 
able interval  the  hair  will  itself  tell  of  the  great  improvement 
that  has  taken  place.  In  certain  morbid  conditions  the  hair 
has  a  great  tendency  to  split  at  the  ends.  A  good  story  is 
told  about  the  late  Professor  Laycock,  that  from  observing 
the  split  ends  of  the  hair  in  one  case  he  was  able  to  diagnose 
aortic  valvulitis.  The  absolute  truthfulness  of  this  story, 
however,  cannot  be  guaranteed ;  but  it  is  not  impossible 
that  this  took  place,  as  Professor  Laycock  certainly  did 
make  observations  quite  as  wonderful. 

Good  strong  hair,  like  good  teeth,  is  usually  found  with 
a  good  constitution ;  the  exceptions,  as  said  before,  being 
found  in  certain  strumous  persons. 

The  Forehead. — The  formation  of  the  forehead  is  at  times 
indicative  of  the  individual.  When  high  and  well-vaulted 
it  tells  of  the  nervous  diathesis.  Commonly  this  goes  with 
the  thin  flank,  the  Arab  type ;  and  then  the  individual  has 
Arab  proclivities,  likes  tea  or  coffee,  and  is  fond  of  the  sex. 

2—2 


20  PHYSIOLOGICAL  FACTOR  IN  DIAGAOSIS. 

While  the  broad,  low  brow  goes  with  the  broad  square 
abdomen  and  large  digestive  organs :  this  gives  the  old 
Norse  type,  good  eaters  and  drinkers,  with  a  heaven  con- 
sisting of  a  drinking-hall,  as  contrasting  with  the  Arab 
harem.  These  latter  take  alcohol  kindly,  and  care  little  for 
tea  or  coffee  ;  but  they  drink  in  moderation — for  them,  for 
they  usually  can  drink  considerable  quantities  with  impu- 
nity. They  may  degenerate  into  sots,  but  the  true  neurosal 
dipsomaniac  belongs  to  the  first  class  usually.  To  observe 
these  types  when  manifested,  commonly  gives  a  clue  both 
to  their  maladies  and  their  management  in  each  class. 

Then  the  forehead  may  be  protuberant,  and  such  is  often 
seen  with  the  earthy  complexion  and  sunken  nose  of  con- 
genital syphilis  in  strumous  families.  The  rachitic  child 
has  also  a  protuberant  forehead,  with  the  centres  of  the 
bones  well  ossified,  but  with  gaping  fontanelles.  '  The 
head  of  the  child  in  rickets  is  generally  unusually  large, 
the  vertex  flattened,  and  the  forehead  prominent,  broad, 
and  square,  with  considerable  expansion  on  the  centres  of 
the  parietal  bones.'  Sometimes  the  sutures  remain  unclosed, 
as  in  chronic  hydrocephalus;  or  become  closed  too  early  and 
firmly,  as  in  the  cretin  and  the  idiot,  where  the  intellect 
remains  childish — a  child's  brain  being  locked  up  in  the 
osseous  case.  A  small  skull,  however,  is  not  essential  to 
imbecility.  The  arrested  development  of  the  facial  bones 
may  make  the  protuberant  forehead  even  more  conspicuous. 
The  forehead  may  carry  with  it  a  moral  significance,  and  the 
broad  eburnated  forehead  was  that  of  which  Jeremiah  said, 
'  Thou  hadst  a  whore's  forehead,  thou  refusedst  to  be 
ashamed ' — a  matter  at  times  worth  noting.  Then  there 
may  be  a  rash  around  the  edge  of  the  hair,  which  may  be 
measles,  or  may  be  the  coronal  rash  of  syphilis.  Or  a  solitary 
copper-coloured  spot  may  tell  its  eloquent  tale.  Ulceration 
of  the  forehead,  especially  when  serpiginous,  either  as  an 
ulcer  or  as  a  scar,  is  pathognomonic  of  syphilis  ;  care  being 
taken  to  ascertain  that  it  is  not  the  result  of  an  injury. 


EXTERNAL  APPEARANCE.  21 

The  Eyebrow. — The  eyebrows  are  often  either  very  arched 
or  abnormally  straight  in  some  strumous  persons.  They  are, 
too,  unusually  thick  or  even  bushy  in  some  cases ;  and 
persons  with  such  thick  arched  or  straight  eyebrows  are 
bad  subjects  for  phthisis.  Then  severe  prolonged  or  repeated 
facial  neuralgia  may  lead  to  increased  growth  of  the  eyebrow 
at  the  outer  extremity,  with  a  deeply  pigmented  patch  of 
skin  around  it.  A  perpetual  frown  indicates  either  mental 
depression  or  persistent  suffering,  commonly  abdominal. 

The  Eyelashes. — In  persons  of  robust  constitution  these 
are  usually  short  and  firm.  In  strumous  children  they  are 
commonly  long,  full,  and  silken,  giving  a  pleasing  expression 
to  the  eye.  Indeed,  the  long  eyelash  goes  with  the  full  lip 
and  alee  nasi  of  struma,  which  may  unite  to  give  a  very 
piquant  expression.  At  other  times  there  is  an  opposite 
condition,  the  eyelashes  being  broken  and  stumpy,  with 
suppuration  around  their  roots,  and  the  expression  is  repul- 
sive, there  being  ophthalmia  tarsi,  sometimes  with  ectropion 
or  entropion. 

The  Eyelids. — Beyond  nervous  indications  (to  be  given 
further  on)  the  inner  aspect  of  the  eyelids  will  commonly 
tell  correctly  of  the  presence  or  absence,  and  the  amount* 
of  anaemia  present  in  a  case,  and  are  often  scrutinized  for 
that  end.  AX,  times,  however,  the  eyelid  can  tell  something 
very  significant.  Thus,  in  certain  individuals,  the  lower 
eyelid  is  swollen  or  '  puflfed  '  on  rising  in  the  moi'ning. 
This  may  occur  with  elderly  persons,  even  of  high  com- 
plexion, but  is  most  common  with  pallid,  middle-aged 
ladies ;  it  indicates  Bright's  disease,  with  the  large  white 
kidney.  At  other  times  the  eyelids,  indeed  the  orbit  gene- 
rally, are  the  seat  of  distinct  pigmentation  ;  this  may  either 
occur  as  a  transient  affair  at  the  catamenial  periods,  or  be 
present  more  persistently  in  the  discolourations  produced 
by  pregnancy.  Some  individuals  are  very  liable  to  these 
pigmentations,  which  recur  in  them  again  and  again.  A 
quiver  of  the  fibrillee  of  the  eyelids  will  at  times  tell  of 
nervous  trouble,  alcoholism  for  instance. 


22  PHYSIOLOGICAL  FACTOR  IN- DIAGNOSIS. 

The  Eye. — This  can  furnish  much  information  if  read 
aright.  The  eye  is  oblique  in  many  cretins  and  imbeciles, 
who  may  present  the  IVIongolian  type  of  feature  in  other 
respects.  In  exophthalmic  goitre  the  eye  is  unduly  promi- 
nent ;  and  the  prominence  may  be  slight,  so  as  to  give  a 
look  of  interest  to  the  case,  or  so  pronounced  as  to  be  very 
unsightly.  It  varies  in  amount  from  time  to  time.  Then 
the  conjunctivge  may  be  stained  with  bile  when  the  jaundice 
is  so  slight  as  not  to  be  discernible  in  the  skin ;  or  it  may 
be  injected  in  the  chronic  alcoholic,  with  the  large  vessels, 
quite  tortuous  or  serpentine ;  or  a  choroidal  flush  may  show 
itself  In  some  cases  of  Bright's  disease  the  conjunctiva  is 
pearly- v/hite,  or  blue-white.  In  the  'Bright  eye'  there  is  a 
drop  of  fluid  behind  the  conjunctiva,  which  looks  like  a 
tear  ;  only  it  can  be  moved  about,  which  is  not  the  case  with 
a  tear.  The  cornea  may  be  ulcerated  in  conditions  of  mal- 
nutrition, or  bear  the  scar  of  by-past  ulceration ;  or  it  may 
be  opaque  from  keratitis,  the  result  of  inherited  syphilis, 
which  does  not  show  itself  in  this  form  until  after  puberty. 
The  opaque  cornea,  the  sunken  bridge  of  the  nose,  and  the 
pegged  teeth  J  when  found  together,  constitute  a  unique  and 
pathognomonic  physiognomy  ;  but  it  is  well  to  know  each 
detail  of  the  whole,  so  as  to  be  able  to  appraise  it  when  found 
alone. 

Then  there  is  the  well-known  arcus  senilis.  Now  arcus 
means  a  bow,  or  an  arch,  and  is  not  a  ring  (annidus)  ; 
consequently  it  is  *  the  senile  arch,'  not  '  the  senile  ring.' 
It  is  found  first  as  a  rainbow  under  the  upper  eyelid ;  then 
a  like  arcus  forms  under  the  lower  eyelid ;  ultimately  the 
two  join,  and  then  a  ring  is  formed.  Such  is  the  arcus  senilis, 
of  which  much  has  been  written  vaguely.  It  must  be  borne 
in  mind,  too,  that  there  is  a  '  true  '  and  a  '  false '  arcus ;  the 
first  being  full  of  significance,  while  the  latter  is  of  no  con- 
sequence, diagnostically  or  otherwise.  The  latter  is  the 
more  palpable,  however;  it  consists  of  a  ring  of  fine  cal- 
careous deposit  at  the  union  of  the  cornea  and  the  sclerotic. 


EXTERNAL  APPEARANCE.  23 

where  there  is  a  ring  of  bony  plates  in  certain  birds ;  when 
the  surgeon's  knife  passes  this  ring,  a  slight  sense  of  grating 
is  experienced.  The  '  false '  arcus  is  often  seen  very  marked 
in  people  with  light-blue  eyes,  and  this  white  ring  gives  a 
bird-like  expression  to  the  eye.  Its  outlines  are  distinct 
and  clearj  while  the  cornea  is  perfectly  transparent  within 
the  ring.  The  'true '  arcus  consists  of  two  segments,  which 
approach  each  other  and  unite  in  time.  It  is  a  development 
of  fat-granules,  and  is  the  outward  visible  sign  of  tissue- 
degeneracy.  This  arcus  has  badly  defined  edges,  especially 
on  the  inner  surface ;  while  the  cornea  is  hazy  and  cloudy 
from  a  development  of  fat-granules  throughout  its  structure 
— the  expression  of  the  eye  is  largely  lost  in  many  cases  in 
consequence  thereof.  Such,  then,  are  the  '  true '  and  '  false  ' 
arcus,  and  it  is  well  to  discriminate  the  two  in  practice.  The 
'true'  form  is  significant;  the  'false'  is  usually  seen  in  per- 
sons free  from  any  degenerative  changes.  In  estimating  the 
probability  of  fatty  degeneration  in  a  heart  clearly  wanting 
in  vigour,  the  true  arcus,  taken  along  with  evidences  of 
atheromatous  changes  in  the  arterial  walls,  is  often  of  great 
value. 

Then  as  to  the  pupils.  They  may  be  dilated,  and  often 
are  so,  in  ansemia ;  on  the  other  hand  they  may  be  con- 
tracted, as  in  opium-poisoning,  or  even  from  indulgence  in 
lozenges  containing  opium  or  morphia.  Marked  diff'erence 
of  size  in  the  pupils,  one  being  decidedly  contracted,  is 
suggestive  of  aneurysm.  The  pupils  are  of  varying  size  in 
several  conditions,  which  will  be  discussed  in  a  succeeding 
chapter.  The  immobility  of  the  pupil  to  light  is  often  of 
considerable  diagnostic  value ;  as  to  the  size  of  the  pupil  as 
a  guide  in  the  administration  of  belladonna,  it  is  simply 
nonsense.  For  years  I  have  given  belladonna  very  freely, 
and  it  is  the  exception,  and  the  rare  exception  too,  to  find 
the  pupil  affected.  Besides,  what  of  it  when  it  does  occur  ? 
It  is  too  meteoric  to  be  of  any  value  when  found.  The 
man   who    would   stop    the   administration    of  belladonna 


24  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS.  f 

merely  because  the  pupil  is  dilated,  is  as  unreflective  as 
the  man  who  would  not  stop  it  because  the  pupil  was  not 
altered,  though  there  might  be  other  and  valid  reasons  for 
suspending  its  administration.  (Even  when  there  is  dryness 
of  the  throat  and  dimness  of  vision,  or  even  difficulty  in 
emptying  the  bladder,  it  is  by  no  means  necessary  to  stop 
the  belladonna  if  it  is  doing  good,  as  in  arresting  the  night- 
sweats  of  phthisis;  where  it  is  invaluable  if  boldly  but  judi- 
ciously used.) 

Then  the  iris  may  tell  its  tale.  The  red  iris  suggests 
syphilis,  the  common  cause  of  iritis.  Or  a  tubercle  may 
be  seen  protruding  into  the  pupil ;  or  a  scar  may  tell  where 
inflammation  once  has  been ;  or  the  size  and  shape  of  the 
pupil  may  be  altered. 

The  eye  is  also  an  organ  of  expression,  and  as  such  may 
be  studied  with  advantage.  The  gaze  will  often  tell  of  a 
resolute  disposition,  or  of  wavering  courage.  An  unsteady 
gaze  tells  that  the  individual  cannot  be  relied  upon,  either 
from  want  of  courage,  or  want  of  purpose,  or  inherent 
deceptiveness.  The  secret  drinker  rarely  has  a  steady  eye. 
The  liar  may  have  it,  however.  Usually  much  depends 
upon  the  eye  of  the  observer,  and,  if  steady  enough,  the 
other  will  usually  quail.  It  is  well  always  to  watch  the 
eye,  when  doubts  are  entertained  as  to  the  veracity  of  a 
person,  during  both  the  questions  and  the  answers.  The  eye 
is  often  more  truthful  than  the  tongue.  In  all  relations  of 
life,  the  question  of  mastery — in  other  words,  the  settlement 
of '  the  will-fight ' — frequently  crops  up,  and  the  eye  is  the 
organ  with  which  the  matter  is  decided.  Two  people  look 
each  other  in  the  eye,  and  they  recognise  each  other's  posi- 
tion ever  after.  When  in  doubt  as  to  whether  a  patient  is 
going  to  adopt  the  advice  given,  or  spurn  it,  it  is  well  to 
catch  the  eye,  and  the  decision  is  soon  known. 

In  conditions  of  insanity,  the  gaze  has  a  recognised  value. 
There  is  the  downcast  eye  of  melancholia,  the  vacant  stare 
of  dementia,  the  glare  of  suspicion  and  distrust,  the  excited 


1 


EXTERNAL  APPEARANCE.  25 

look  of  mania,  or  the  elated  air  of  the  general  paralytic 
with  his  unequal  pupils.  By  study  of  the  expression  of  the 
Gy6>  you  Difi-y  learn  whether  you  have  an  obedient  or 
mutinous  patient  to  deal  with  :  a  piece  of  diagnosis  far  from 
valueless  in  prognosis  and  treatment. 

The  Nose, — Perhaps  some  anatomical  details  are  scarcely 
to  be  classed  under  '  the  physiological  factor  in  diagnosis/ 
but  the  features  cannot  be  included  under  'the  physical 
signs.'  They  belong  to  the  individual  rather  than  any  par- 
ticular morbid  condition,  and  can  still  less  have  a  division 
of  their  own ;  so,  to  prevent  their  entire  omission,  they  may 
not  unfitly  be  considered  here. 

There  is  the  play  and  quiver  of  the  nostrils  in  thoracic 
disease,  or  in  nervous  excitement,  undistinguishable  almost 
except  bj''  other  accompanying  phenomena.  Then  the  sunken 
bridge  tells  of  the  'snuffles'  of  infancy  in  the  inheritor  of 
syphilis,  where  the  chronic  inflammation  has  bound  down 
the  nasal  bones,  and  arrested  their  growth.  In  struma  the 
alse  nasi  are  full  and  tumid,  as  is  the  upper  lip.  There  is 
the  red  tuberous  or  bulbous  nose  of  the  drinker,  a  condition 
sometimes  closely  simulated  by  disease.  Then  there  is  the 
red  tip  of  females  with  indigestion  and  constipation,  with 
or  without  pelvic  complications.  Or  the  nose  may  be  abnor- 
mally pale.  Cold  feet  go  with  both  conditions,  and  the 
indications  so  given  point  to  the  appropriate  treatment. 

The  Lips. — The  full  lip  of  struma  has  been  spoken  of 
before.  When  not  too  pronounced,  the  strumous  face  is  an 
attractive  one ;  but  when  very  marked,  the  thick  lip  and 
coarse  nose,  often  with  swellings  of  the  glands  of  the  neck, 
brutalize  the  face.  The  lips  are  often  blue  or  purple,  as  in 
the  cyanosis  of  congenital  heart-imperfection ;  or  in  venous 
fulness  from  cardiac  valvulitis,  or  other  thoracic  disease  in 
which  the  right  heart  is  embarrassed.  A  temporary  fulness 
and  coarseness  of  the  lips  often  follows  excessive  sexual 
indulgence.  The  full  under  lip  tells  of  a  sensual  disposition, 
a  hint  pregnant  with  information  at  times.     Scars  at  the 


26  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

angles  of  the  mouth  abnost  invariably  tell  of  inherited 
syphilis.  An  herpetic  rash  on  the  lips  is  commonly  accom- 
panied by  a  certain  amount  of  pneumonia ;  and  when  found 
with  a  cold,  it  is  well  to  examine  for  the  other.  Sordes  on 
the  lips  belongs  to  the  typhoid  condition,  to  be  considered 
later  on. 

The  Gums. — These  furnish  little  information,  but  when 
they  do,  it  is  well  worth  attention.  Thus  in  lead-poisoning 
there  is  a  blue  line  along  the  edge  of  the  teeth,  which  when 
seen  is  pathognomonic.  Then  there  may  be  ulceration  along 
the  line  of  the  gums  and  the  teeth,  indicating  a  cachectic 
condition.  At  times  the  gums  are  foetid  and  spongy,  as  in 
mercurial  salivation,  not  often  seen  now.  Or  they  may 
present  a  spongy  state  with  blood  oozing  from  them,  as  in 
purpura,  or  scurvy.     They  are  morbidly  pallid  in  anaemia. 

The  Teeth. — Much  may  be  gleaned  from  observation  of  the 
teeth.  First,  however^  be  certain  that  the  teeth  are  natural 
products  ;  the  dentist  copies  the  natural  teeth  now  so  care- 
fully, that  it  is  not  always  easy  to  determine  their  nature. 
Well-shaped  teeth,  badly-formed  teeth,  white  teeth,  yellow 
teeth,  any  kind  of  teeth  can  be  matched  by  the  dentist 
now !  The  teeth  may  tell  of  excessive  indulgence  in  tobacco, 
or  of  mere  uncleanliness  in  the  individuaL  Or  they  may 
be  stained  by  chalybeates.  Or  there  may  be  caries,  telling 
its  own  tale.  This  may  be  inherited  delicacy,  the  structure 
of  the  tooth  being  defective,  so  that  it  readily  yields  to  the 
causes  of  caries  ;  or  that  these  are  favoured  by  the  practices 
of  the  individual,  as  excessive  indulgence  in  sweets  with 
the  acid  formed  therefrom.  The  teeth  may  look  well,  but 
the  molars  may  be  largely  decayed ;  and  herein  lies  much 
indigestion  from  imperfectly  masticated  food.  Strumous 
persons  are  specially  liable  to  caries,  and  their  teeth  com- 
monly present  a  bluish  line  around  the  carious  spot,  or 
edge.  Then  the  teeth  may  be  injured  by  mercury,  when 
they  look  *  dirty '  rather  than  blue  around  the  decaying 
portion.       Gouty  teeth   are   solid   and   heavily   enamelled. 


EXTERNAL  APPEARANCE.  27 

although  not  always  large.  Sometimes  the  two  upper  front 
teeth  are  very  large  in  the  gouty  diathesis.  The  large 
massive  well-formed  teeth  of  some  gouty  persons  are  very 
useful  at  times  in  helping  to  aid  the  diagnosis  of  suppressed 
gout.  The  gouty  are  liable  to  lose  their  teeth  without  any 
caries ;  the  tooth  comes  out  perfectly  sound  from  periostitis," 
which  gradually  thrusts  it  out  of  its  socket. 

The  teeth  of  inherited  syphilis  have  been  specially  studied 
by  that  excellent  observer,  Jonathan  Hutchinson,  who  has 
arrived  at  the  following  conclusions :  '  It  is  very  common 
to  find  all  the  incisor  teeth  dwarfed  and  malformed.  These 
teeth  are  narrow  and  rounded,  and  peg-like ;  their  edges  are 
jagged  and  notched.  Owing  to  their  smallness,  their  sides 
do  not  touch,  and  interspaces  are  left.  It  is,  however,  the 
upper  central  incisors  which  are  the  most  reliable  for  pur- 
poses of  diagnosis.  When  the  other  teeth  are  affected,  these 
very  rarely  escape,  and  very  often  they  are  malformed  when 
all  the  others  are  of  fairly  good  shape.  The  characteristic 
malformation  of  the  upper  central  incisors  consists  in  a 
dwarfing  of  the  tooth,  which  is  usually  both  narrow  and 
short,  and  in  the  atrophy  of  its  middle  lobe.  This  atrophy 
leaves  a  single  broad  notch  (vertical)  in  the  edge  of  the 
tooth ;  and  sometimes  from  this  notch  a  shallow  furrow 
passes  upwards  on  both  anterior  and  posterior  surfaces 
nearly  to  the  gum.'  Mr.  Hutchinson  is  careful  not  to  push 
this  matter  of  the  teeth  further  than  it  can  go  legitimately, 
so  that  in  most  cases  the  teeth  can  raise  the  suspicion  only 
rather  than  decide  the  question  of  syphilis.  Sometimes  in 
undoubted  syphilis  (congenital)  the  teeth  escape ;  but  there 
may  be  fissures  at  the  angle  of  the  mouth,  which  tell 
unmistakably. 

The  permanent  teeth  only  present  these  tell-tale  charac- 
teristics ;  the  first  set  are  liable  to  decay,  but  present  no 
peculiarity  in  shape.  Nor  must  *  craggy  teeth,'  with  their 
horizontal  furrows,  be  confounded  with  what  are  now  known 
as  '  Hutchinson's  teeth,'  with  vertical  furrows.     Many  chil- 


28  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

dren  of  delicate  constitution  have  teeth  notched  vertically, 
with  the  absence  of  the  fourth  denticle.  When  there  is  a 
small  jaw  in  which  the  teeth  are  crowded,  these  variations 
in  development  are  commonly  present.  So  that  it  will  not 
be  prudent  to  rush  to  a  conclusion  from  the  teeth  alone. 
Syphilis  is  an  '  imitator,'  as  Mr.  Hutchinson  teaches,  and 
mimics  conditions  set  up  by  other  morbid  states.  Perhaps, 
too,  it  may  grave  deeper  at  times  the  mark  due  to  something 
else  originally.  Naturally,  ill-developed  teeth  are  more 
likely  a  'priori  to  manifest  the  evidence  of  syphilis  than 
are  well-developed  teeth. 

The  Chin. — The  chin  is  often  indicative  of  the  diathesis. 
A  broad  square  jaw  goes  with  the  gouty  diathesis ;  while 
a  light  slender  jaw  is  linked  with  the  nervous,  or  the 
strumous  diathesis. 

The  Ears. — The  ear  may  exhibit  otolites,  the  evidence  of 
gout.  Or  it  may  have  a  lobe  full,  red,  glistening,  as  if 
about  to  burst,  like  a  ripe  fig;  such  a  lobe  tells  of  the 
full-fed  gouty  person  at  middle  age.  As  time  goes  on  the 
tenseness  is  diminished,  and  the  lobe,  though  fleshy,  is 
wrinkled.  In  others  again  the  lobe  is  seamed  with 
wrinkles_,  just  as  is  the  skin  of  the  face.  In  such  cases 
there  is  a  spare  organism  with  a  tendency  to  visceral 
cirrhosis.  Or  the  ear  may  be  deformed.  This  may  be 
due  to  some  violence  to  it ;  it  may  be  the  oethsematoma  of 
the  general  paralysis  of  the  insane.  A  discharge  from  the 
ear  should  always  put  the  medical  man  upon  his  guard  as 
to  the  possible  extension  of  the  mischief  to  the  meninges  of 
the  brain;  a  not  uncommon  consequence,  almost  alwaj^s  fatal. 

The  Neck. — The  neck  may  present  the  enlarged  glands  of 
scrofula,  or  the  scars  of  by -past  suppuration  in  the  glandulie 
concatinatsB.  The  glands  may  be  enlarged — the  '  wax- 
keinels,'  as  they  are  termed  in  the  north — from  some 
condition  of  the  mucous  lining  of  the  throat;  like  the 
sympathetic  bubo  of  gonorrhoea.  Or  a  large  gland  may 
remain  after  scarlatina  or  measles,  or  be  due  to  disease  of 


EXTERNAL  APPEARANCE.  29 

the  cervical  vertebrte.  Or  the  thyroid  gland  may  be  enlarged. 
This  may  be  due  to  a  local  varicosity  of  the  thyroid  vessels. 
More  commonly  it  is  part  of  Graves'  disease,  exophthalmic 
goitre.  Here  the  eyes  are  prominent,  and  the  heart  has  an 
excited  action.  The  eyes  are  less  prominent  at  times  than 
usual,  or  more  so ;  and  so  is  the  goitre.  Under  what 
circumstances  these  changes  occur  are  not  yet  known. 
Then  the  thyroid  gland  is  found  enlarged  in  certain 
localities  in  England,  *  the  Derbyshire  neck  ;'  it  has  been 
asserted  that  this  change  is  found  mainly  in  limestone 
districts.  It  has  been  known  to  be  linked  with  the  water 
of  certain  wells ;  those  not  drinking  the  water  of  a  particular 
well  escaping,  while  their  neighbours  who  drank  of  it 
suffered.  It  is  without  significance,  so  far  as  is  known. 
Sometimes  the  gland  is  enlarged  generally,  at  other  times 
the  enlargement  is  unilateral.  Or  there  may  be  '  wry  neck,' 
due  to  cold  or  rheumatism ;  or  perhaps  a  neurosal  affection, 
or  it  may  be  due  to  a  burn.  Or  there  may  be  a  'stiff  neck,' 
telling  of  an  abscess,  or  anchylosis,  or  muscular  stiffness. 

The  muscles  of  the  neck  are  often  charged  with  signifi- 
cance. In  confirmed  emphysema  the  sternal  muscles  stand 
out  like  cords  in  the  inspiratory  act ;  drawing  up  the  im- 
movable thoracic  walls  while  the  diaphragm  descends.  In 
dyspnoea  the  action  is  violent  in  these  accessory  muscles  of 
the  respiration.  The  bloodvessels  of  the  neck,  too,  often 
speak  eloquently.  In  aortic  regurgitation  with  enlarge- 
ment of  the  aorta  and  its  branches,  the  pulsations  of  the  huo-e 
heart  are  readily  seen  in  the  vessels  at  the  root  of  the  neck. 
Or  the  pulsation  of  an  aneurysm  is  detected,  sometimes  on 
both  sides ;  or  maybe  of  an  abscess  lying  over  the  carotid 
artery.  At  other  times  it  is  the  veins  that  are  full,  and 
pulsate  from  a  current  of  blood  being  driven  backwards 
through  an  insufficient  tricuspid  valve,  on  the  S3'stole  of  the 
right  ventricle.  This  may  be  temporary  or  permanent.  Or 
at  times  it  may  be  found  without  actual  tricuspid  incom- 
petency. 


f 


30    '       niYSlOLOGICAL  FACTOR  IN  DIAGNOSIS. 

The  Thorax. — The  shape  of  the  thorax  is  not  without 
interest.  There  may  be  the  hump-back,  telling  of  by-past 
spinal  caries,  leaving  the  individual  liable  to  early  failure 
of  the  heart,  with  dropsy  and  the  other  outcomes  thereof. 
The  barrel-shaped  chest  of  typical  emphysema  is  very 
instructive.  When  seen  "with  the  cord-like  muscles  of  the 
neck,  the  injected  countenance,  the  protuberant  abdomen, 
the  diagnosis  of  chronic  bronchitis  with  emphysema  is  made  ; 
physical  examination  only  corroborates  it.  Then  there  is  the 
flat,  narrow  chest  of  the  typically  phthisical.  Such  chest, 
however,  is  not  incompatible  with  emphysema.  Then  there 
are  the  pointed  wing-like  shoulders  of  the  chronic  asthmatic. 
When  these  are  seen  in  a  comparativel}"  young  subject, 
while  the  back  projects,  the  prospect  of  the  case  is  very  bad. 
The  shoulders  are  dragged  forward  by  the  action  of  the 
pectoral  muscles,  in  their  function  as  accessory  muscles  of 
respiration.  The  importance  of  the  shoulders  being  thrown 
backwards,  like  a  soldier's,  is  seen  whenever  the  respiration 
is  tested  by  an  acute  malady.  Some  other  matters  con- 
nected with  the  character  and  rapidity  of  the  respiration 
will  be  discussed  further  on  (Chapter  IV.) 

The  Abdomen. — This  may  be  flat  in  emaciated  conditions  ; 
but  more  commonly  it  is  fuller  rather  than  flatter  than 
normal.  Thus  it  is  enlarged  in  ascites,  in  ovarian  disease, 
uterine  fibroids,  or  pregnancy.  It  is  also  enlarged  in  '  pot- 
belly '  (tabes  mesentericus),  and  in  amjdoid  disease  of  the 
liver  in  children.  Often,  however,  these  are  simulated  by 
a  tense  tympanitis.  In  old  persons  it  may  be  due  to  cancer. 
In  other  cases  the  abdomen  is  protuberant  from  a  pad  of 
fat  over  it.  When  this  is  conspicuous  without  corpulency 
elsewhere,  it  is  suggestive  of  free  living  ;  and  when  seen 
in  comparatively  young  subjects,  carries  with  it  a  bad  look- 
out as  to  length  of  days.  In  confirmed  dyspeptics  the 
abdomen  is  often  flat ;  indeed  usually  so,  except  when  there 
is  much  flatulence  present.  Sometimes  the  respiration  will 
be  distinctly  abdominal,  telling  of  thoracic  embarrassment. 


I 


EXTERNAL  APPEARANCE.  31 

The  Hand. — This  should  alwaj's  be  observed,  as  it  has 
often  a  good  deal  to  tell.  A  large  knuckle  may  tell  of 
gout ;  or  more  than  one  joint  may  be  affected. 

The  thumb  is  rarely  implicated  except  at  its  carpal  articu- 
lation. But  the  forefinger  is  the  common  seat  of  gout,  either 
at  the  terminal  joint  or  the  knuckle,  or  there  may  be  gouty 
concretions  in  the  sheaths  of  the  tendons.  The  middle  finger 
shares  in  the  deformity  very  often,  but  scarcely  to  the  same 
extent.  In  some  cases  the  hand  has  enlargements  in  every 
finger.  In  other  cases  a  finger  is  drawn  down  by  gouty 
inflammation  in  the  sheath  of  its  flexor  tendon.  The  patient 
will  tell  you  that  it  is  due  to  his  walking-stick,  or  umbrella, 
if  in  the  right  hand  ;  or  if  in  his  left,  that  it  is  from  the 
blows  of  his  geologic  hammer,  or  other  cause  of  local  injury. 
But  on  examining  his  other  hand,  it  will  be  found  there  too 
to  a  less  extent.  Sir  James  Paget  holds  such  pathological 
condition  to  be  due  to  gout ;  indeed  is  pathognomonic 
thereof.  In  rheumatic  gout  there  is  also  thickening  of  the 
knuckles,  while  the  fingers  are  bent  away  from  the  thumb. 
In  rheumatic  gout  the  subjects  are  usually  young,  often 
women ;  while  in  gout  the  reverse  is  the  case.  The  hand 
may  be  deformed  from  rheumatism  due  to  exposure;  or  the 
knuckles  may  be  larger  from  repeated  violence,  suggestive 
of  fisticuffs.  At  other  times  the  knuckles  are  prominent 
from  wasting  of  the  interossei  muscles  throwing  up  the 
epiphyses  in  strong  relief. 

Then  the  epiphyses  are  actually  large  in  persons  of  the 
strumous  diathesis.  This  is  well  seen  in  the  hand  of  Dr. 
Johnson,  of  dictionary  fame  ;  and  his  hand  and  face  are  well 
worthy  of  study  whenever  the  opportunity  occurs,  for  they 
are  well  marked.  In  girls  the  joints  may  be  seen  large, 
with  very  slender  shafts  to  the  finger-bones.  The  large 
joints  obstruct  the  getting  off  and  on  of  rings.  Such  hand 
is  often  very  useful  diagnostically.  It  is  seen  in  rickety 
children,  as  part  of  the  general  condition  of  fulness  of  the 
epiphyses;  often  well  seen  in  'the  rachitic  garland,' the  little 


32  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

festoon  of  prominences  where  the  ribs  give  off  the  costal 
cartilages. 

Then  there  are  the  '  clubbed  fingers '  of  valvular  disease, 
cono-enital  heart  deficiency,  and  also  of  chronic  phthisis. 
These  are  seen,  indeed,  whenever  embarrassment  of  the 
pulmonary  circulation  leads  to  venous  fulness ;  and  I  have 
seen  it  very  marked  in  early  emphj^sema.  It  is  said  that 
there  is  incurvature  of  the  nails  in  phthisical  clubbed  fingers. 

In  cyanotic  states,  the  clubbed  ends  are  often  very  blue 
or  purple.  Sometimes  the  nails  are  livid  when  there  is 
want  of  tone  in  the  vascular  system.  Here  the  hands 
sometimes  '  die/  and.  become  white  and  cold  like  the  hand 
of  a  corpse.  Here  there  is  vaso-motor  spasm.  Such  con- 
dition is  common  in  the  gouty,  or  the  subjects  of  granular 
kidney.  In  others  the  veins  are  full  and  prominent.  This 
may  be  due  to  contracted  arteries.  A  transparent  hand 
with  conspicuous  blue  veins  tells  of  debility. 

The  hand  is  often  damp  and  clammy ;  and  this  '  wet ' 
hand  is  held  in  the  United  States  to  indicate  nervous 
exhaustion  in  which  the  reproductive  system  has  played 
a  part.  This  damp  hand,  which  sweats  the  colour  out  of 
their  gloves  at  the  palm,  is  often  found  with  girls  where 
there  is  a  large  generative  expenditure,  with  leucorrhcea 
usually.  This  wet  hand,  with  distinct  hair  on  the  upper 
lip,  is  held  by  Dr.  Greenhalgh  to  be  associated  with  secret 
practices ;  and  certainly  sodden  fingers  with  black  *  hang- 
nails '  tell  distinctly  of  what  their  owners  would  little  like 
to  be  known.  In  feeling  the  pulse  the  fingers  (ring  and 
little)  often  make  an  observation  of  cold  dampness  not 
readily  revealed  to  the  eye. 

The  hand  will  often  tell  of  toil  or  idleness,  and  so  give 
a  clue  to  the  patient's  habits,  not  without  value  in  some 
cases. 

When  there  is  a  suspicion  of  jaundice,  it  is  well  to  stretch 
the  skin  over  the  back  of  the  hand,  when  the  yellow  tinge 
is  often  seen  quite  unmistakably. 


EXTERNAL  APPEARANCE. 


33 


The  hand  may  tell  of  paralysis,  and  the  late  rigidity 
which  follows.  Or  the  skin  may  glisten,  telling  of  nerve- 
injuries.  The  fingers  are  closed  in  some  cases  of  hysteria  ; 
or  there  is  a  wave-like  motion  in  athetosis.  The  irresular 
movements  of  chorea,  either  unilateral  or  bilateral, 
are  well-known.  Rhythmic  movements  of  the  hands 
are  common  with  imbecile  children.  In  some  idiots,  Dr. 
Langdon  Down  has  pointed  out,  there  is  a  *  woolly  hand  ;' 
the  skin  being  quite  too  large  for  the  framework  of  the 
hand. 

Some  further  changes  in  the  hand  will  be  referred  to  in 
Chapter  X. 

The  Nails. — The  nails  are  often  pregnant  with  suggestion. 
But  the  eye  must  be  familiar  with  nails,  in  order  to  dis- 
tinguish correctly  betwixt  a  naturally  indifferent  nail,  and 
a  good  nail  modified  by  some  morbid  agency  aflfecting  it. 
Nails  consist  of  agglutinated  hairs.  In  defective  nails,  this 
is  usually  readily  seen.  In  gouty  individuals  with  well- 
shaped  nails  the  same  is  seen,  so  that  this  striation  of  the 
nail  has  at  times  a  high  practical  value.  In  my  own  case, 
each  touch  of  gout  will  leave  its  impress  on  several  nails, 
and  the  position  of  the  mark  it  leaves  tells  of  its  date  until 
it  is  effaced  by  the  growth  of  the  nail.  This  gouty  nail  is 
usually  attended  by  some  brittleness,  which  prevents  its 
being  kept  neatly  trimmed.  Scudamore  noted  in  the  gouty 
'  a  remarkable  state  of  hardness  in  the  nails  of  the  toes  and 
fingers ;  they  had  an  extraordinary  brittleness  ;  were  fran- 
gible and  scarcely  capable  of  being  cut.'  The  nails  often 
bear  the  traces  of  a  by-past  illness^  and  so  suggest  a  question 
sometimes  not  unimportant.  Dr.  B.  W.  Richardson  thinks 
psoriasis  of  the  nails  associated  with  a  dartrous  diathesis. 
In  this,  Mr.  Jonathan  Hutchinson  agrees  with  him.  Mr. 
Hutchinson  thinks  that  the  white  patches  on  nails,  known 
as  '  flowers  '  or  '  lies,^  are  '  often  seen  in  the  nails  of  children 
and  delicate  persons  who  are  in  the  habit  of  picking  the 
nail  at  the  root,  and  thus  injuring  its  soft  structures.'     It 

3 


34  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

takes  about  seven  months  for  a  nail  to  grow  out  any  such 
mark  or  patch. 

The  Feet — While  scrutinizing  the  hand,  it  is  well  to  cast 
the  eye  over  the  feet.  These  may  exhibit  nodosities,  which 
may  tell  of  bunions  or  of  chrouic  gout.  When  there  is  a 
recent  slit  in  the  shoe,  probably  there  is  present  an  acute 
attack  of  gout;  or  the  foot  has  been  subject  to  an  injury. 
Or  the  feet  may  be  misshapen  by  rheumatic  gout,  the  great 
toe  beine:  folded  in  under  the  other  toes. 

Then  the  unlaced  shoe  may  tell  of  oedema ;  or  in  milder 
cases  the  stocking  and  swollen  ankle  may  project  over  the 
top  of  the  laced  boot  or  shoe.  The  unlaced  shoe,  with  the 
■waistcoat  and  the  band  of  the  trousers  tied  with  string, 
because  the  buttons  cannot  be  approximated  to  the  button- 
holes, tells  unmistakably  of  dropsy.  Or  the  patient  may 
suffer  from  corns. 

The  Gait. — This  is  worth  noting.      The  patient  may  have 
a  high-heeled  shoe,  telling  of  osseous  trouble  in  the  past ; 
or  he  may  have  a  cork  leg  ;  or  he  may  limp  from  a  sprain, 
or  a  tight  boot,  or  maybe  a  leg-bone  badly  set  after  being  ; 
broken ;  or  he  may  be  knock-kneed ;  or  the  tibia  may  be  i 
curved  from  early  rickets.     In  rheumatic  gout  of  the  hip-  '• 
joint  the  affected  leg  is  swung  round  in  walking,  rather  than  :; 
lifted  up  ;  and  the  same  occurs  when  the  knee  is  anchylosed. 
This  is   obvious;    if  the  leg  cannot  be  lifted  it  must  be 
advanced  by  swinging  it  round.     In  children  with  morbus 
coxarius   the   pelvis   is   tilted   up   upon  the  diseased  side 
in  order  to  swing  round  the  leg.      '  In  the  early  stage  the 
limb  is  usually  straight,  carried  slightly  forward,  or  perhaps 
somewhat  abducted,  owing  to  the  irritation  and  contraction 
of  the  capsular  muscles  on  the  anterior  and  outer  aspects  of 
the  joint.  As  the  disease  advances  the  limb  becomes  adducted, 
so  that  the  knee  is  carried  against  the  lower  part  of  the  sound  |. 
thigh.' — (Erichsen.)  |l 

The  gait  may  be  modified  by  intoxication,  acute  or  chronic. 

The  gait  of  the  various  nervous  affections  will  be  given 
further  on  (Chapter  X.) 


EXTERNAL  APPEARANCE.  35 

The  Clothes. — The  eye  can,  in  its  survey,  take  in  the 
arrangement  of  the  patient's  clothes.  So  long  as  they  are 
neat  and  clean,  the  patient's  attention  is  clearly  not  taken 
away  from  his,  or  her,  appearance.  When  indifference  to 
the  dress  is  exhibited,  then  there  is  either  some  disease  of 
the  cerebral  hemispheres  setting  in,  or  the  patient  is  too  ill, 
or  too  absorbed,  to  attend  to  the  dress.  The  drunkard  is 
first  dirty,  then  unwashed  with  unbrushed  clothes,  and  then 
ragged :  alcohol  is  gradually  depriving  him  of  care  as  to 
appearances.  In  failing  brain-power  the  same  indifference 
to  the  raiment  is  manifested.  The  coat-collar  is  not  turned 
down,  or  the  waistcoat  is  buttoned  awry,  or  the  trousers 
are  partially  unbuttoned,  or  the  shoe  is  down  at  heel.  At 
times  in  glycosuria  the  marks  of  the  urine  are  left  in  white 
sugary  streaks,  or  in  splashes  on  the  lower  portion  of  the 
trousers.  Or  in  distinct  diabetes  the  trousers  may  be  seen 
even  rotten,  with  the  saccharine  urine,  at  the  fork.  In 
incontinence  of  urine  the  trousers  are  wet  with  the  dribbling 
fluid. 

In  a  drinking  bout,  a  fit  of  drunkenness  lasting  over  some 
days,  the  drunkard  may  attire  himself  grotesquely,  as  do 
certain  lunatics. 

Indeed,  the  clothes  will  sometimes  reveal  a  good  deal. 

The  Manner. — This,  too,  is  also  suggestive  at  times. 
Country  people,  out  much  in  the  open  air,  have  a  certain 
rude  health  and  brusqueness  of  manner  contrasting  with 
the  sedate  quietness,  which  rather  characterizes  those  who 
lead  a  sedentary  life,  or  serve  behind  the  counter.  Then 
there  is  the  bustling  irritability  of  sufferers  from  suppressed 
gout,  as  well  as  the  restlessness  which  tells  of  anxiety.  The 
chronic  invalid  usually  carries  an  air  of  languor,  with  a 
certain  self-consciousness.  The  lady  with  the  vapours  is 
often  got  up  with  strict  attention  to  appearances.  The 
masturbator  usually  has  an  eye  which  is  ever  unsteady, 
with  an  averted  gaze.  It  is  an  eye  you  cannot  '  catch  ;'  it 
eludes  all  attempts  to  fix  it.      The  same  is  seen  in  many 

3—2 


36  rHYSIOLOCICAL  FACTOR  IN  DIAGNOSIS. 


girls  when  pregnant ;  though  at  times  they  assume  an 
attitude  of  defiant  indignation^  or  maybe  of  brazen-faced 
impudence. 

The  Vascularity  of  the  Face. — Having  completed  the 
general  survey  of  the  individual,  it  is  well  to  study  care- 
fully the  evidences  furnished  by  the  vascular  supply  of  the 
face.  So  far  as  the  hue  of  the  skin  is  concerned  this  has 
been  spoken  of  before  (p.  16). 

Now  something  more  precise  may  be  discussed.  There 
may  be  vascular  fulness  from  an  overcharged  circulation,  or 
plethora.  Or  the  high  complexion  may  be  due  mainly  to 
exposure,  as  is  seen  very  marked  in  some  engine-drivers^ 
It  indicates  arterial  fulness  whenever  the  colour  is  crimson. 
It  is  much  darker  and  purple  in  hue  when  the  vascularity 
is  venous.  Exposure  calls  for  a  free  vascular  supply  to  pro- 
tect the  tissues  against  the  efi'ects  of  cold.  Or  pallor  may 
tell  of  an  indoor  occupation  rather  than  of  ill-health  :  one 
who  bends  long  hours  over  the  desk,  or  who  lives  the  live- 
long day  in  a  mill  or  a  printer's  office,  can  scarcely  be  ex- 
pected to  exhibit  a  very  high  complexion.  There  is  the  flush 
of  hectic,  which  is  to  be  distinguished  from  the  peach-bloom 
of  florid  health,  of  '  bloodvessels  largely  developed  over  the 
malar  bones  and  varicosed,'  which  Professor  Laycock  held 
to  indicate  the  sanguine  gouty  cachexia.  The  terminal 
branches  of  a  small  artery  will  sometimes  be  seen  to  pierce 
the  skin  abruptly,  and  course  along  the  surface.  These 
dendritic  twigs  are  part  of  a  wdde-spread  atheromatous- 
change  in  the  arterial  walls ;  and  so  often  furnish  most 
useful  information.  They  go  usually  with  a  hard  pulse 
and  thickened  arteries,  of  which  the  temporal  may  be  dis- 
tinctly visible  ;  an  hypertrophied  left  ventricle,  and  an 
accentuated  aortic  second  sound — the  chanp-es,  indeed,  of 
the  granular  kidney.  The  correlated  physiological  state  i 
is  that  of  a  copious  flow  of  urine^  usually  pale  ;  and  a  \ 
tendency  to  get  up  in  the  night  to  empty  the  bladder. 
This  last  association  will  often  enable  the  medical  observer 


EXTERNAL  APPEARANCE.  yj 

to  put  a  pertinent  question,  which  impresses,  as  it  ought 
to  do,  the  patient  very  considerably.  Aortic  dilatation* 
aneurysm,  palpitation  (unconnected  with  effort),  angina  pec- 
toris, and  apoplexy  (from  ruptures)  go  with  the  tense  artery 
of  the  *  gouty  heart '  (p.  9). 

The  temporal  artery,  though  inarticulate,  may  at  times 
speak  volumes.  It  may  be  seen  tortuous,  thickened,  and 
elongated.  Each  pulse  may  be  visible  in  it,  even  without 
aortic  regurgitation.  The  wall  may  be  very  thick,  and 
comparatively  soft  and  compressible  ;  or  it  may  be  thinner, 
but  hard  and  wiry.  The  first  goes  with  well-nourished 
gouty  individuals;  the  latter  with  the  spare  subjects  of 
visceral  cirrhosis.  The  condition  of  the  visible  temporal 
artery  ought  always  to  direct  the  attention  to  the  rest  of 
the  arterial  system.  In  aortic  regurgitation  the  elongation 
and  the  widening  of  the  arterial  lumen  is  often  to  be  seen 
very  distinctly,  as  '  the  ball  of  blood  is  shot '  along  the 
vessel ;  and  the  sudden  collapse  of  the  vessel  calls  up  the 
sensation  given  to  the  finger  in  this  lesion — the  '  water- 
hammer  pulse,'  or  '  Corrigan's  pulse.'  Such  pulse  tells  of 
insuflSciency,  with  little  or  no  obstruction  at  the  aortic 
orifice. 

In  certain  young  men  who  have  led  very  studious  lives, 
the  temporal  artery  may  be  at  once  conspicuous  and  tortuous 
without  any  significance ;  especially  if  there  be  little  sub- 
cutaneous fat.  On  the  other  hand,  in  some  young  men  the 
temporal  artery  is  seen  thickened  and  tortuous  under  a 
parchment-like  skin  tightly  stretched  over  the  tissues 
beneath.  On  several  occasions  this  species  of  temporal 
artery  has  been  found  linked  with  syphilis ;  and  when  seen 
it  is  well  to  look  for  a  syphilitic  rash,  or  the  stain  of  one. 

Venous  fulness  is  revealed  in  a  '  mitral  flush  '  and  injection 
of  the  face ;  or  in  lividity  with  blueness  of  the  lips,  and 
bloated  features. 

In  arterial  ansemia  the  lips  and  the  inner  surface  of  the 
lower  eyelid  are  very  pale  and  exsanguine. 


38  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS.  I 

Such,  then,  is  the  information  gleaned  by  the  eye  as  it 
takes  in  point  after  point  in  its  inspection  of  the  patient : 
an  inspection  with  far  wider  range  than  the  inspection  of 
the  bared  chest — though  that  is  valuable  enough  in  its  turn. 
It  cannot  all  be  learnt  from  a  mere  perusal  of  a  printed 
page.  The  reader  must  think  it  over  until  it  has  become 
a  part  of  himself,  of  the  information  which  he  carries  about 
with  him  habitually.  The  whole  system  is  a  hieroglyph 
in  itself  which  has  merely  to  be  learnt,  to  the  great  benefit 
of  him  who  takes  the  trouble  to  interpret  it.  Semeiology 
is  the  special  training  of  the  eye,  *  which  can  only  see  what 
it  carries  with  it  the  power  to  see.'  Little  indications  may 
point  the  direction  which  the  inquiries  should  take ;  often 
saving  much  bootless  questioning,  as  well  as  giving  the  clue 
to  well-placed  questions.  And  well-put  judicious  questions 
tell  the  patient,  and  even  more  the  patient's  friends,  that 
the  medical  man  knows  what  he  is  about;  while  vague 
aimless  questionings  neither  succeed  in  gaining  confidence^ 
nor  deserve  to  do  so  ! 

Not  only  may  much  be  learned  by  the  eye  as  to  the 
physique  of  a  patient,  but  many  psychical  traits  are  revealed 
to  the  educated  gaze.  This  may  stand  the  medical  man  in 
good  stead  when  dealing  with  strangers  ;  maybe  in  com- 
plicated matters  where  it  is  as  well  to  *  walk  warily.' 

'  How  class  you  your  man  %  as  better  than  the  worst  %  ■ 

Or  seeming  better,  worse  beneath  that  cloak  %  | 

As  saint  or  knave  ?  pilgrim  or  hypocrite  ?'  " 

Thus  wrote  that  novelist  who  possessed  the  keenest  insight 
into  human  nature,  George  Eliot ;  whose  works  all  medical 
men  should  study  carefully. 

Such,  then,  is  the  information  to  be  gathered  by  steady 
systematic  inspection  of  the  patient.  The  fulness  of  the 
bloodvessels,  the  inherited  constitution,  the  presence  of  a 
source  of  cachexia,  reveal  themselves  to  the  educated  eye ; 
matters  of  great  value  in  other  respects  than  mere  diagnosis, 
but  for  it  often  invaluable. 


CHAPTER  III. 

THE   TONGUE. 

The  study  of  the  surface  of  the  tongue  is  probably  as  old  as 
medicine  itself  The  aspect  of  the  tongue  is  so  modified  by 
different  morbid  conditions,  while  it  is  so  readily  scrutinized, 
that  this  is  no  matter  for  surprise.  It  is  the  only  portion 
of  the  alimentary  tract  which  admits  of  easy  scrutiny.  It 
has  been  held  that  the  condition  of  the  tongue,  the  part 
observable,  is  suggestive  of  the  condition  of  the  rest,  the 
non-observable  portion  of  the  mucous  lining  of  the  alimen- 
tary canal.  Probably  most  persons  will  admit  that  there  is 
much  to  be  said  for  this  view;  though  there  may  be  circum- 
stances which  tend  to  invalidate  the  value  of  its  evidence 
upon  some  occasions.  For  instance,  redness  of  the  tongue 
may  occur  without  inflammatory  conditions  of  a  portion  of 
the  gastro-intestinal  canal ;  as  these  may  exist  without 
notable  redness  of  the  tongue. — (Flint.) 

The  manner  in  which  the  tongue  is  protruded  is  often 
highly  suggestive.  When  the  patient  is  in  the  typhoid 
state,  whether  in  connection  with  true  fevers  or  prolonged 
pyrexial  states  which  have  led  to  ursemic  conditions,  the 
tongue  is  protruded  slowly  ;  and  often  only  after  loud  and 
repeated  requests.  The  intelligence  is  deeply  clouded  here; 
and  the  tongue  is  perhaps  only  withdrawn  after  similar 
requests.  If  at  the  same  time  it  is  obviously  tremulous,  then 
it  suggests  great  muscular  debility,  and  in  so  far  is  of  bad 
omen.  It  may  also  be  observed  to  be  tremulous  as  a  part 
of  the  condition  known  as  delirium  tremens ;  or  it  may 
be  tremulous  in  certain  nervous  persons.     It  is  tremulous 


40  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

frequently  in  lead  or  mercurial  poisoning.  A  child  almost 
instinctively  protrudes  its  tongue  when  in  the  presence  of  a 
medical  man;  and  Austin  Flint  makes  the  observation — 
*  It  is  a  curious  fact  that  patients  will  frequently  protrude 
the  tongue  when  they  cannot  be  made  to  do  aught  else, 
owing  to  the  state  of  their  mental  faculties.' 

The  indications  furnished  by  the  tongue  as  to  more 
especial  states  of  the  nervous  system  will  be  reviewed  in 
Chapter  X. 

The  first  thing  to  be  done  is  to  induce  the  patient  to  put 
out  the  tongue  fully.  It  is  no  use  to  study  the  tip,  which 
is  often  clean  when  the  rest  of  the  tongue  is  thickly  coated. 
The  tongue  must  be  put  out  so  as  to  bring  the  circumvallate 
papillae  into  sight.  Females  often  fail  to  do  this  when  re- 
quested. They  seem  to  desire  to  keep  '  the  unruly  member ' 
from  observation.  Then  babies  cannot  be  told  to  put  out 
the  tongue ;  or  if  told  would  not  comply  with  a  request 
which  they  could  not  comprehend.-  With  these  it  is  well  to 
adopt  the  plan  recommended  by  Sir  William  Jenner,  viz.,  put 
a  drop  of  fluid,  all  the  better  if  viscid  like  syrup,  upon  the 
little  one's  chin.  The  tickling  sensation  so  produced  will 
lead  it  to  try  to  remove  the  source  of  imtation  by  the 
tongue;  and  while  the  tongue  is  so  employed,  its  condition 
may  be  studied  without  any  disturbance  to  the  child.  When 
a  mutinous  child  obstinately  refuses  to  put  out  its  tongue, 
a  little  pressure  on  the  ramus  of  the  jaw  will  usually  induce 
it  to  open  its  mouth. 

In  children  the  tongue  is  not  usually  much  furred ;  but 
it  may  present  the  evidences  of  stomatitis,  or  aphthous 
patches,  telling  of  general  debility.  These  aphthous  patches 
are  spoken  of  vulgarly  as  '  the  thrush  ;'  which  is  regarded  as 
a  disease  itself,  rather  than  as  the  outcome  and  evidence 
of  a  state  of  adynamy. 

Then  the  tongue  is  dry  in  diabetes  mellitus,  or  other  con- 
dition where  the  bulk  of  urine  is  large  ;  in  cases  where  the 
patient  sleeps  with  his  mouth  open ;  and  is  also  found  dry  in 


THE  TONGUE.  41 

acute  pyrexia.  Or  this  may  be  due  to  the  frequent  inspira- 
tion in  embarrassed  respiration.  It  may  be  so  dry  as  to 
be  almost  horny.  In  the  typhoid  state  it  may  be  thickly 
coated  with  a  brown  fur,  and  even  fissured.  In  some 
epidemics  of  fever  the  tongue  becomes  coated  with  a  black 
fur — '  as  black  as  your  hat,'  I  have  heard  my  father  say  of 
the  tongue  in  the  severe  outbreaks  of  fever  (typhoid)  in  the 
dales  of  the  Lake  Mountains  in  past  times.  The  surface 
of  the  tongue  may  be  stained  by  iron,  black-currant  j  uice, 
bilberries,  elder  juice^  Spanish  liquorice,  or  tobacco,  or 
treacle  and  tea  taken  together ;  or  it  may  be  livid  in 
cyanosis,  pale  in  ansemia,  or  yellow  in  jaundice;  or  it  may 
be  abnormally  red  from  the  recent  shedding  of  an  epithelial 
coat.  It  may  bear  the  marks  of  syphilitic  patches,  or  sto- 
matitis; or  a  chancre  may  be  found,  or  a  commencing 
cancer;  or  an  ulceration  from  a  jagged  tooth,  or  an  accu- 
mulation of  tartar  behind  the  front  teeth  of  the  lower  jaw. 

Or  the  edge  may  be  indented  from  long  pressure  on  the 
teeth.  This  may  indicate  hebetude,  as  in  comatose  condi- 
tions where  the  tongue  has  lain  long  in  one  position  undis- 
turbed; or  may  be  due  to  a  swollen  state,  part  of  a  general 
condition  of  asthenia.  It  is  liable  to  be  so  swollen  and 
indented  in  females  who  are  the  subject  of  mennorhagia, 
with  or  without  leucorrhcea.  When  so  swollen  and  indented, 
and  also  presenting  a  sort  of  silvery  sheen,  it  is  very  sugges- 
tive of  such  combinations.  Or  the  tongue  may  present  deep 
fissures,  which  suggest  syphilis  ;  or  the  scars  of  bites  inflicted 
in  epileptic  seizures.  A  number  of  slight  fissures  are  often 
exhibited  on  the  tongues  of  persons  who  drink  freely  of 
very  hot  fluids,  as  tea,  for  instance ;  though  these  are  not 
pathognomonic. 

The  great  clinical  interest  in  the  appearance  of  the 
tongue  lies,  however,  in  the  matter  of  whether  the  tongue 
be  coated,  furred,  or  frosted  ;  or  be  bare  or  raw,  that  is,  de- 
nuded of  epithelium.  Especially  for  the  matter  of  treatment 
in  any  case  is  the  condition  of  the  tongue  of  cardinal  moment. 


42  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

If  it  be  raw,  one  line  of  treatment  is  indicated  ;  if  furred, 
another.  For  instance,  in  a  case  of  apex-consolidation  with 
active  symptoms — what,  indeed,  might  fairly  be  termed 
phthisis  pulmonalis  in  an  early  stage— the  condition  of  the 
tongue  is,  to  my  mind,  the  indication  for  treatment.  If  it 
be  fun-ed,  with  loss  of  appetite,  then  a  bitter  infusion  with 
an  acid  is  indicated  ;  but  if  raw,  this  will  quickly  make  the 
patient  worse.  Whenever  the  tongue  is  either  denuded  of 
epithelium  or  covered  with  young  epithelium,  then  alkalies 
with  bismuth  are  called  for.  But  it  is  not  only  in  phthisis 
in  its  early,  or  indeed  any  stage,  that  this  rule  is  to  be 
observed  ;  it  should  be  made  a  rule  in  practice  to  be  steadily 
adopted  in  all  cases,  unless  there  be  some  very  strong  reason 
indeed  to  diverge  from  it.  The  old  practitioners  who  pinned 
their  faith  to  Mist.  Tragacanth  Co.,  with  an  alkali  in  the 
treatment  of  phthisis,  had  a  great  deal  of  reason  on  their 
side.  Careful  scrutiny  of  the  condition  of  the  tongue  and 
thoughtful  reasoning  therefrom  is  far  more  important,  to  the 
patient  at  least,  than  any  amount  of  physical  examination, 
in  the  bulk  of  cases.  This  last  will  tell  of  the  extent  of  the 
mischief,  even  whether  it  is  static,  progressive,  or  softening 
is  going  on,  or  that  a  cavity  has  been  formed — will,  indeed, 
go  far  to  establish  the  diagnosis.  But  we  cannot  treat  phthisis 
pulmonalis  by  any  specific  remedy :  we  must  follow  the 
indications  furnished,  or  otherwise  'treat  the  symptoms.' 
And  this  I  say  with  my  foot  down  solidly ;  yet  in  full  vivid 
consciousness  that  it  will  be  condemned  by  those  who  think 
that  the  management  of  phthisis  lies  in  '  diagnosis ;'  after 
which  the  treatment  evolves  itself  by  a  natural  process  of 
sequence,  as  the  flower  follows  the  bud,  or  the  chick  is 
developed  from  the  egg. 

The  furred  or  coated  tongue  is  not  indicative  of  any 
special  malady.  'A  coated  tongue  occurs  in  a  host  of 
diseases.  It  is  evidence  that  the  system  is  disordered,  but 
it  does  not  point  to  either  the  seat  or  the  nature  of  the 
malady.' — (Flint.)    Some  persons  never  have  a  clean  tongue, 


THE  TONGUE.  43 

yet  seem  to  have  good  health.  Heavy  smokers  have  furred 
tongues,  especially  in  the  mornings.  Tipplers  have  white,  or 
yellowish-white  tongues ;  and  after  a  debauch  the  tongue 
is  often  very  thickly  furred.  Such  tongue,  when  also  tremu- 
lous, is  very  suspicious  ;  no  matter  what  the  professions  of 
its  owner  !  In  atonic  dyspepsia  the  tongue  is  white,  pretty 
uniformly  over  its  surface.  Here  there  is  usually  constipa- 
tion. Flint  also  describes  a  '  malarial  tongue,'  which,  as  it 
may  interest  other  than  English  readers,  may  be  quoted 
here  :  '  A  uniform,  white  and  thin  covering,  extending  over 
the  whole  dorsal  surface,  giving  an  appearance  as  if  the 
surface  were  chalked  or  covered  with  white  paint,  is  often 
observed  in  patients  with  intermittent  fever,  and  is  some- 
times called  a  malarial  tongue.  This  is  somewhat  charac- 
teristic' 

When  the  tongue  is  uniformly  white,  and  at  the  same 
time  there  is  languor,  a  sense  of  malaise,  with  shivering, 
then  there  is  some  acute  fever  looming,  or  it  may  be  acute 
inflammation.  When  it  seems  clean,  but  a  yellow  stain  is 
visible  on  putting  the  tongue  in  a  side-light,  and  looking 
along  it  as  a  dyer  does  with  a  skein  of  silk  or  wool,  then 
the  liver  is  disordered.  At  other  times  there  is  a  yellow 
or  brown  fur,  mainly  up  the  middle  of  the  tongue,  with  a 
bad  taste  in  the  mouth,  sometimes  bitter,  sometimes  hot, 
on  awakening  in  the  morning ;  and  here  the  liver  is  cer- 
tainly not  working  properly.  Here  most  men  of  clinical 
experience  would  admit  the  liver  to  be  at  fault,  even  if  they 
will  not  allow  the  stainins:  to  be  due  to  bile.  Tauro-cholic 
acid  may  not  stain,  but  it  goes  with  the  staining  matter. 
The  bitter  taste  may  not  be  due  to  bile  ;  but  it  is  probably 
due  to  those  by-products  of  digestion,  such  as  Wm.  Roberts 
found  to  be  produced  towards  the  completion  of  the  digestive 
act  when  carried  on  out  of  the  body.  By  regulation  of  the 
dietary,  and  measures  directed  to  the  liver,  such  condition 
will  usually  be  readily  relieved.  The  taste  is  not  due  to  the 
fur,  which  may  be  thick,  yet  devoid  of  taste  ;  it  is  something 
superadded  to  the  fur. 


44  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

The  fur  consists  of  dead  epithelium-cells,  particles  of  food, 
vomited  matters  at  times,  dust  inhaled  by  the  breath,  and 
parasitical  growths.  Consequently,  there  is  little  absorption 
possible  through  such  layer.  When  seen  upon  the  tongue, 
it  is  believed  to  exist  upon  the  whole  intestinal  tract. 
'  Watch  a  case  of  typhoid  fever,  and  see  what  immediate 
improvement  follows  the  shedding  of  the  dead  epithelium 
with  which  the  mucous  membranes  have  been  coated — a 
change  which  is  announced  by  what  is  called  the  "  cleaning 
of  the  tongue,"  but  which  foreshadows  much  more,  in  fact 
the  cleaning  of  the  whole  intestinal  tract.' — (King  Chambers.) 
To  clean  the  tongue  is  to  promote  absorption  ;  that  is  a 
clinical  fact  testified  to  by  universal  experience.  This  layer 
of  dead  epithelium-cells  must  be  removed.  Consequently, 
we  carefully  inspect  the  tongue  to  see  if  it  '  is  cleaning,'  in 
acute  disease,  and  in  convalescence.  When  the  tongue 
commences  to  clean,  we  look  upon  it  as  the  herald  of  a 
better  state  of  things ;  the  crisis  is  past,,  and  the  system 
is  rallying.  When  the  fur  again  collects,  we  look  out  for  a 
relapse.  Often,  however,  this  is  nothing  more  than  the 
indication  of  an  overload  of  the  digestive  organs,  from  well- 
meant  but  mistimed  efibrts  to  push  the  convalescence,  to 
'  make  the  patient  strong ;'  a  by  no  means  uncommon 
occurrence  in  this  age  of  cramming  the  sick  and  weak. 
When  the  tongue  is  seen  to  be  cleaning,  then  the  prospect 
is  good.  The  cleaning  process  usually  commences  at  the 
edges  and  spreads  therefrom  ;  a  strip  of  fur  being  left  along 
the  mesial  line,  more  particularly  towards  the  base  of  the 
tongue,  the  last  to  go.  It  may  not  be  the  practice  in  hos- 
pitals to  examine  the  tongue  every  morning,  but  it  is  usual 
to  do  so  in  private  practice  ;  and  a  very  good  rule  it  is,  too. 

One  of  the  best  evidences  of  returning  power  in  a  patient 
who  has  been  acutely  ill,  is  the  power  of  the  mucous  lining 
of  the  alimentary  canal  to  shed  its  coating  of  dead  epithe- 
lium ;  of  which  the  condition  of  the  tongue  is  the  accepted 
outward  visible  sign.     Of  old  it  was  customary  to  aid  the 


THE  TONGUE.  45 

natural  efforts  by  a  dose  of  calomel  at  bedtime;  nor  was 
this  '  bad  practice,'  though  opposed  to  our  present  notions. 
Sometimes,  no  doubt,  nature  could  achieve  tliis  without  any- 
such  aid ;  and  the  following  case  impressed  me  very  power- 
fully early  in  ray  professional  career.  A  boy  was  ill  with 
threatening  enteritis.  He  was  progressing  favourably,  and 
on  the  evening  visit  it  seemed  desirable  to  administer  a 
calomel  powder ;  as  my  father  certainly  would  have  done. 
But  the  figure  of  John  Hughes  Bennett  loomed  up,  and 
I  decided  to  leave  the  case  alone.  Next  morning  the  boy 
had  had  two  copious  semi-fluid  motions,  and  the  tongue 
was  quite  clean.  Had  he  had  the  powder,  unquestionably 
it  would  have  got  the  credit  of  this  change.  Admitting 
this  freely,  I  am  now  more  inclined  to  look  upon  this  as 
rather  an  exceptional  occurrence  ;  and  to  veer  round  to  the 
old  practice  of  giving  a  calomel  powder  after  opiates  have 
been  administered,  and  the  tongue  is  foul,  rather  than 
waiting  to  see  what  nature  can  do  unaided. 

(And  here  a  slight  digression  may  be  permissible.  Th& 
treatment  of  inflammatory  conditions  by  calomel  and  opium, 
the  plan  introduced  by  Dr.  Hamilton,  of  Lyme  Regis,  has. 
unquestionably  done  much  harm  ;  so  much  that  it  has  almost 
disappeared.  Yet  a  word  may  be  pleaded  for  it.  It  was 
the  abuse  of  the  plan,  the  routine  giving  of  repeated  doses- 
of  calomel  without  thought  or  discretion,  which  is  to  be 
condemned — ^just  as  any  other  blind  following  of  any  plan 
is  to  be  condemned — rather  than  the  addition  of  some 
calomel  to  free  doses  of  opium  !  It  is  '  misuse  '  which  leads 
to  '  disuse.'  At  the  risk  of  being  designated  a  laudator 
tempoyns  acti,  a  plea  must  be  put  forward  in  favour  of  that 
dose  of  calomel  at  times.  Whenever  opium  has  to  be  given 
repeatedly  for  some  time,  the  tongue  becomes  furred,  and 
the  appetite  vanishes.  This,  it  seems  to  me,  is  the  result  of 
the  unsought  but  unavoidable  action  of  the  opium  upon  the 
liver  ;  while  there  is  usually  constipation  from  the  eflfects  of 
the  opiate  upon  the  vermicular  action  of  the  bowels.    'It 


46  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

is  well,  then,  in  strong  organisms,  to  give  some  mercurial, 
which  acts  upon  the  liver,  and  cleans  the  tongue  after 
repeated  doses  of  opium.*  The  impression  is  strong  within 
me  that  the  freedom  from  such  results  with  Dover's  powder 
is  due  to  the  union  of  the  ipecacuan  with  the  opium  ;  which 
keeps  the  liver  in  action.  The  addition  of  some  aloes  to 
night- pills  containing  opium  has  seemed  to  me  to  obviate 
the  ill-effects  of  liver  stagnation  and  constipation  to  a  great 
extent.  This  discussion  may  seem,  at  first  sight,  out  of  place ; 
but  surely  diagnosis  is  not  thrown  overboard  when  con- 
valescence sets  in  ?  It  is  as  important  to  attend  scrupu- 
lously to  the  physiological  data  in  convalescence,  as  in  an 
earlier  date.  And  the  condition  of  the  tongue  is  in  many 
respects  the  finger-post  of  the  convalescent  stage.  When 
opium  must  be  given  in  repeated  doses,  it  is  well  to  give 
therewith  some  hepatic  stimulant,  to  obviate  its  lethargic 
action  on  the  liver.     That  is  the  moral  of  this  digression  !) 

So  long  as  the  tongue  is  foul,  or  tinged  with  the  colouring 
matter  of  bile,  it  is  well  to  withhold  chalybeates.  Iron  given 
before  its  appropriate  time  only  upsets  the  liver  and  dis- 
orders the  digestion.  Neither  is  it  desirable  to  adminster 
iron  so  long  as  the  epithelial  coating  of  the  tongue  is  imper- 
fect. It  is  just  as  desirable  to  watch  the  effects  of  remedial 
agents  as  of  the  disease  upon  the  system  generally,  and  the 
primse  vice  in  particular,  in  order  to  make  a  correct  diagnosis 
of  the  patient's  state. 

Mechanical  means  of  cleaning  the  tongue  are  useless  as 
remedial  agents,  though  often  such  cleansing  is  very  grateful 
to  the  patient.  In  acute  conditions  and  in  great  debility, 
such  cleaning  of  the  tongue  is  pleasant,  and  especially  so 
when  accomplished  by  means  of  vinegar  or  lemon-juice  ; 
and  the  cleansing  process  may  well  include  the  teeth.  But 
as  to  any  curative  effect  to  be  looked  for  from  such  measures 
it  is  nonsense  :  though  some  persons  with  habitually  foul 

*  Mercury  was  the  only  well-recognised  hepatic  stimulant  of  that 
day. 


I 


THE  TONGUE.  47 

tongues  spend  much  time  in  cleansing  them,  only  they  do 
not  go  the  right  way  about  it,  viz.,  to  attend  to  the  condi- 
tions upon  which  the  state  of  the  tongue  causally  depends. 

In  scarlet  fever  the  tongue  often  presents  a  peculiar 
appearance  known  as  '  the  strawberry  tongue.'  Here  there 
are  enlarged  red  papillae  prominent,  like  the  seeds  on  a  red 
strawberry ;  in  other  cases  these  papillae  stand  out  through 
a  white  fur,  and  then  the  appearance  resembles  a  white 
strawberry  with  red  seeds  on  its  surface. 

The  opposite  condition  of  the  '  raw,'  or  '  bare,'  or '  irritable' 
tongue  has  not  had  that  attention  bestowed  upon  it — by 
medical  writers  at  least — which  its  importance,  in  ray 
opinion,  deserves.  Sometimes  the  greater  portion  of  the 
tongue,  especially  along  the  centre,  is  smooth  and  glazy  in 
appearance,  as  if  papillae  and  epithelium  alike  had  dis- 
appeared, except  at  the  edges  ;  at  other  times  the  tongue 
looks  unnaturally  clean,  and  as  if  its  epithelium  was  young, 
or  only  half-grown — it  is  too  smooth,  but  not  glazed.  In 
both  these  conditions  there  is  great  gastric  excitability,  often 
extending  to  vomiting.  Bland  food,  a  milk  dietary,  or  milk 
with  farinaceous  matter,  are  imperative.  Then  bismuth 
with  alkalies,  with  or  without  opium  as  the  case  may  be, 
is  the  medicinal  measure  to  be  adopted  and  steadfastly 
adhered  to.  No  matter  what  may  be  the  disease  affecting 
the  patient,  this  is  the  line  to  be  taken  when  the  tongue  is 
denuded  of  epithelium.  If  the  medical  man  is  lured  away 
by  the  apparent  necessity  for  attention  to  some  other  matter, 
say  a  mitral  lesion,  where  he  might  wish  to  give  digitalis 
and  iron,  for  instance — certainly  a  laudable  wish,  he  errs ; 
he  will  find  it  prudent  not  to  take  the  step  until  the  condi- 
tion of  the  alimentary  canal  will  permit  of  it.  Disaster  after 
disaster  has  followed  divergence  from  this  rule  in  my  experi- 
ence, dating  back  almost  thirty  years  (for  I  was  apprenticed 
to  my  father  in  1854,  and  have  been  familiar  with  sick 
people  ever  since,  except  when  at  school).  First  the 
disaster   occurred    with    myself;    after   that   with   others. 


48  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

There  is,  it  seems,  a  *  murder-stage '  of  medical  education 
when  a  man  is  acquiring  that  knowledge  which  no  medical 
school  can  give  him.  Gaining  it  for  himself :  with  some 
advantage  to  the  undertaker  in  the  meantime  !  Any  man 
may  make  a  blunder  from  an  ignorance  which  cannot  well  be 
helped,  and  which  is  not  blameworthy ;  but  it  is  going  on 
blundering  without  finding  it  out,  which  is  so  much  to  be 
deplored  in  every  way.  Therefore  I  wish  to  impress  this 
matter  upon  the  young  practitioner  in  his  own  interests 
and  in  those  of  his  patients ;  not  desiring  him  to  attend 
thereto  for  the  gratification  of  my  vanity,  nor  to  believe  it 
because  it  happens  to  be  written  here.  Follow,  then,  the 
good  old  time-honoured  plan  of  attending  to  the  primes 
vise  so  long  as  they  require  it,  and  letting  other  matters 
stand  in  abeyance — no  matter,  almost,  how  urgent  the  latter 
may  seem  to  be.  With  a  clear  head,  cool  judgment  and 
a  resolute  will,  with  the  decision  begotten  of  knowledge 
indeed,  hold  on  with  a  firm  hand  on  the  wheel,  and  steer 
the  case  along  its  proper  course.  Some  lines  by  Oliver 
Wendell  Holmes  suggest  themselves  here,  and,  though 
quoted  in  another  work,  are  so  appropriate  they  must  be 
given.     A  barque  is  in  'Sun  or  Shadow  '  alternately  :      , 

'  Yet  her  pilot  is  thinking  of  dangers  to  shun — 

Of  breakers  that  whiten  and  roar ; 
How  little  he  cares,  if  in  shadow  or  sun, 

They  see  him  that  gaze  from  the  shore  ! 
He  looks  to  the  beacon  that  looms  from  the  reef, 

To  the  rock  that  is  under  his  lee, 
As  he  drifts  on  the  blast,  like  a  wind-wafted  leaf, 

O'er  the  gulfs  of  the  desolate  sea.' 

The  grand  old  teacher  is  always  worth  reading,  especially 
by  members  of  the  medical  profession,  who  will  never  fail 
to  profit  by  study  of  him.  Bear  him  in  mind  when  tempted 
to  attend  to  anything  else  than  the  leading  indications  in 
a  case.  Watch  the  tongue,  then,  as  the  measure  of  the 
success  attending  your  eff"orts  when  there  is  great  irritability 


THE  TONGUE.  49 

in  the  intestinal  canal.  Diagnosis  applies  to  the  case  gene- 
rally, not  merely  to  the  morbid  change  which  constitutes 
the  disease  (proper)  :  and  the  varying  condition  of  the 
tongue  is  a  physiological  factor  in  diagnosis  of  the  greatest 
moment  in  acute  conditions ;  whether  occurring  in  indi- 
viduals previously  healthy,  or  cropping  up  as  intercurrent 
affections  iri  the  course  of  a  chronic  case.  To  meet  the 
varj'ing  exigencies  of  a  case  as  they  crop  up,  is  quite  as 
important  as  to  make  a  diagnosis  of  the  malady.  The  latter 
is,  to  a  great  extent,  a  matter  of  hospital  education  ;  the 
first  tests  the  individual  as  to  his  capacity  to  think  and  act 
for  himself  in  emergencies.  A  good  medical  man  is  like  a 
skilful  soldier;  he  must  be  able  alike  to  plan  a  campaign 
and  fight  a  battle,  in  order  to  wage  successful  war  with 
disease  in  its  varying  phases.   * 

The  reason  why  it  is  so  desirable  to  maintain  the  integrity 
of  the  epithelial  lining  of  the  alimentary  canal,  is  demon- 
strated by  the  following  quotation  from  Professor  Michael 
Foster:  'After  a  meal,  the  epithelium  cells  of  the  villus  are 
found  crowded  with  fat.  Since  the  striation  of  the  hyaline 
border  of  the  cells  is  not  due  to  pores,  as  was  once  thought, 
the  particles  must  have  entered  into  the  cells  very  much 
as  foreign  particles  enter  the  body  of  an  amoeba.  The 
epithelium  may,  in  fact,  be  said  to  eat  the  fat,'  This  tells 
of  the  importance  of  maintaining  the  epithelium  in  as  perfect 
a  state  as  is  possibly  attainable,  in  cases  where  the  nutrition 
is  imperfect;  notably,  therefore,  in  phthisis  and  other  wasting 
diseases.  In  acute  conditions  the  absorption  of  other  matters 
of  our  aliment  is  effected  by  the  condition  of  the  epithelial 
lining  of  the  intestinal  canal.  The  soluble  matters  of  our 
food  (sugar,  peptones,  and  salts)  pass  through  the  cylindrical 
epithelium  of  the  intestinal  villi :  '  the  intestinal  mucous 
membrane  permits  readily  of  the  passage  of  water  and  of 
soluble  matters'  (McKendrick).  Indeed,  these  structures 
play  a  great  part  in  the  absorption  of  soluble  matters  from 
the  contents  of  the  small  intestines :  '  it  is  generally  believed 

4 


50  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

that  absorption  of  chyle  is  really  effected  by  the  epithelium 
cells  of  the  villi '  (Kirkes).*  Now,  in  acute  conditions,  any 
shedding  of  the  epithelial  layer  of  the  intestinal  canal  strikes 
directly  at  absorption ;  and  therefore  our  first  duty  is  to 
maintain  the  integrity  of  the  epithelium.  If  the  power  to 
take  up  aliment  is  in  abeyance,  the  patient  will  quickly 
sink.  There  may  be  powerful  incentives  to  push  some  other 
line  of  treatment ;  but,  whatever  they  may  be,  they  cannot 
outweigh  the  necessity  for  maintaining  the  absorbent  powers 
of  the  intestinal  lining  membrane.  '  Make  it  a  universal  rule 
that  the  special  'medication  is  never  to  interfere  with  or 
take  the  place  of  the  supply  of  the  materials  of  life  * 
(King  Chambers).  Steadily  watch  the  tongue,  and  by  its 
condition  set  your  sails  from  day  to  day.  If  the  tongue 
grows  more  raw,  either  the  treatment  is  not  sufficiently 
rigorous,  or  the  case  is  going  downhill  despite  all  your 
efforts  ;  and  when  aphthre  or  stomatitis  show  themselves, 
the  danger  is  imminent.  On  the  other  hand,  if  the  epi- 
thelium grows  apace,  and  the  tongue  loses  its  '  beef-steak ' 
or  its  '  glazed '  appearance,  and  regains  its  normal  aspect, 
then  the  case  is  going  on  well.  By  scrutiny  of  the  tongue 
(together  with  the  patient's  position  in  bed,  the  timbre  of 
his  voice,  and  the  grip  of  his  hand),  the  young  practitioner 
will  be  enabled  to  say  whether  the  patient  is  better  or  worse, 
in  answer  to  the  inquiries  put  to  him  each  day;  a  matter  of 
diagnosis  which  old  practitioners  will  tell  him  is  of  the 
greatest  moment  in  acute  conditions  imperilling  life. 

When  the  brown  fur  of  the  typhoid  condition  is  growing 
browner  and  drier,  and  the  sordes  on  the  lips  becoming 
thicker  (the  patient  getting  more  on  his  back  and  into  the 
middle  of  the  bed,  the  eye  growing  lustreless  and  the  hand 

*  The  reader  may  smile  at  a  (quotation  from  Wm.  Senhouse  Kirkes 
(1860),  but  moi'e  recent  works  in  jjhysiology  seem  to  take  the  absorp- 
tion of  truly  soluble  matters  by  the  epithelial  layer  for  granted  ;  and 
discuss  the  method  of  absorption  of  fat  at  length,  as  the  now 
interesting  matter. 


THE  TONGUE.  51 

listless),  then  the  prospects  of  life  are  rapidly  being  blotted 
out.  Wlieii  the  surface  of  the  tongue  becomes  moist,  and 
the  fur  begins  to  clear  away  from  the  edges,  then  the  patient 
belongs  to  the  living ;  if  along  with  this  the  position  is 
■changed  to  the  side,  and  urine  begins  to  flow,  then  the 
prospects  are  brightening.  The  condition  of  the  tongue  is 
the  first  thing  to  observe,  after  which  the  other  matters  may 
be  noted;  and  according  to  the  indications  will  be  the 
remark,  'You  are  feeling  a  little  better  to-day ;'  or  the  other, 
fraught  with  significance,  'Our  poor  friend  is  not  so  well 
to-day:'  all  of  which  young  men  '  fresh  from  the  schools* 
may  hold  to  be  little  better  than  twaddle  ;  but  ten  years 
of  actual  practice  and  experience  at  the  bedside  will  probably 
heighten  their  estimate  of  its  value. 

In  relapsing  fever  there  is  often  a  small  triangular  space  on 
the  tip  of  the  tongue,  about  half  an  inch  along  each  of  its 
three  sides,  which  is  cleaner  and  freer  from  fur  than  the 
rest  of  the  tongue-surface.  This  I  have  seen  both  at  home 
and  in  Germany.  It  may,  when  present,  have  a  high  dia- 
gnostic value  in  a  doubtful  case  seen  for  the  first  time. 

Coldness  of  the  tongue  is  indicative  of  the  moribund 
•condition,  and  especially  in  the  algid  stages  of  epidemic 
cholera  (Flint). 

Some  practitioners  not  only  examine  the  tongue  carefully 
with  the  eye,  but  feel  it  studiously.  This  no  doubt  impresses 
the  patient,  and  is  sometimes  done  for  eSect.  It  may  not  be 
necessary  to  call  in  the  aid  of  the  touch,  but  the  eye  should 
■certainly  be  vigilant  as  to  the  matter  of  the  tongue;  especially 
in  acute  conditions,  when  it  must  be  continued  every  day  or 
oftener. 

Sometimes  the  tongue  will  be  seen  to  clean  by  casting  off 
its  brown  fur ;  but  it  remains  raw  or  '  beef-steaky,'  from 
inability  to  grow  a  new  epithelial  layer.  Here  it  is  well  to 
be  guarded  about  the  prognosis,  for  the  rally  is  but  imper- 
fect ;  and  prognosis  surely  rests  on  accurate  diagnosis !  The 
reappearance  of  any  browning   indicates   a    return  of  the 

4—2 


52  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

typhoid  orurasmic  condition;  or,  maybe,  the  effects  of  opium. 
Whenever  there  is  a  brown  shade  on  the  tongue,  it  is 
desirable  to  look  to  the  medicine  as  well  as  to  the  patient. 

Now,  the  youthful  reader  may  think  that  there  is  much 
in  this  chapter  which  scarcely  belongs  to  diagnosis.  But 
the  diagnosis  of  the  patient's  state  in  acute  conditions 
imperilling  life,  is  as  much  true  '  diagnosis '  as  is  the 
correct  discrimination  of  his  special  malady  ;  and  is  most 
important,  as  he  will  find.  He  may  hold,  too,  that  there  is 
too  strong  a  leaning  to  the  therapeutic  aspect  of  the  case. 
Perhaps  so ;  but  possibly  he  will  forgive  this  after  perusal 
of  the  following  paragraph  :  '  On  stating  in  consultation  an 
opinion  that  some  viscus  is  chronically  degenerated,  one  is 
often  met  by  the  remark,  "  Well,  what  is  to  be  done  ?  We 
cannot  cure  that."  Very  likely  not ;  then  try  and  find 
something  else  which  you  can  cure.  In  the  great  majority 
of  your  patients,  you  may  find  this  curable  something  in 
functional  impediments  to  the  entrance  of  nutriment  into 
the  medium  of  assimilation;  and  when  once  you  can  get 
nutriment  in,  it  will  act  as  the  best  medicine.  Do  not, 
therefore,  give  way  to  despair,  even  after  it  has  become 
certain  that  the  principal  viscus  which  gives  a  name  and 
origin  to  the  disease  is  incurable.  And  repress  any  con- 
scientious fancies  that  you  are  not  fairly  earning  your  fees 
in  giving  careful  attention  and  advice,  though  you  prescribe 
little  for  the  organ  mainly  aff'ected.  It  is  never  too  late  to 
try  and  administer  to  the  failing  organ  the  most  potent  of 
all  medicines,  the  healthy  human  blood  of  the  patient 
himself.'  Such  is  the  outspoken  expression  of  Dr.  King 
Chambers,  whose  words  will  command  the  respect  of  all. 
Further,  to  act  as  he  advises  is  surely  to  earn  the  fee  ten- 
dered, as  compared  to  pronouncing  an  opinion  as  to  the 
nature  of  the  malady,  forbidding  all  hope  ;  and  going  away 
without  trying  to  see  if  something  or  other  may  not  be 
possible  in  the  patient's  interests.  Diagnosis  surely  involves 
treatment  as  well  as  prognosis. 


THE  TONGUE.  53 

There  are  some  other  matters  which  are  so  linked  with 
scrutiny  of  the  tongue  that  they  may  be  considered  here. 
Inspection  of  the  tongue  affords  usually  an  opportunity  for 
noting  the  oral  cavity.  The  eye  may  note  whether  the  teeth 
are  good  and  sound,  or  not — a  matter  not  unimportant  in  dys- 
pepsia; nor  yet  in  facial  neuralgia,  or  other  nervous  conditions. 

The  Roof  of  the  Mouth. — This  is  highl}^  arched  in  imbeciles. 
It  may  be  imperfect  as  a  congenital  defect,  or  have  been 
removed  by  syphilitic  ulceration. 

The  Tonsils. — These  may  be  seen  enlarged,  or  inflamed, 
or  ulcerated.  In  acute  disease  there  may  be  the  film  of 
diphtheria  or  scarlatina.  When  there  is  ulceration,  it  is 
well  to  look  to  the  soft  palate  ;  if  a  grey  ashen  ulcer  be  seen 
there,  then  the  diagnosis  of  syphilis  is  more  than  conjectural. 

The  Uvula. — This  may  be  long,  and  be  the  cause  of  per- 
sistent intractable  cough.  It  may  be  absent,  having  been 
snipped  off  by  the  surgeon,  or  eaten  off  by  syphilis. 

The  Fauces. — Here  again  there  maybe  evidence  of  syphilis. 
Or  there  may  be  follicular  ulceration,  or  enlargement  with 
hypervascularity  ;  or  there  may  be  the  sore  throat  of  putrid 
origin,  or  '  hospital  sore  throat.' 

The  Pharynx. — This  may  share  in  the  condition  of  the 
fauces  in  the  above-mentioned  states  ;  or  there  may  be 
*  clergyman's  sore  throat.'  Enlarged  follicles,  a  varicose 
condition  of  the  pharyngeal  vessels,  with  hypervascularity 
and  either  dryness  and  irritability,  or  the  secretion  of  mucus 
giving  rise  to  hawking,  may  result  from  indigestion ;  at 
other  times  the  local  condition  is  not  so  associated. 

Then  there  are  transient  conditions  of  sore  throat,  where 
there  is  the  redness  of  hypervascularity.  The  following 
description  of  catarrhal  throat  by  King  Chambers  ('Clinical 
Lectures ')  is  so  vivid,  and  so  forcible,  it  calls  for  quotation : 
'  Look  at  your  catarrhal  throat  in  a  mirror — what  do  you 
see  ?  The  surface  red,  puffy,  and  with  the  component 
parts,  such  as  the  uvula,  enlarged.  There  is  also  poured 
out  a  quantity  of  slimy  material,  which  you^well   know 


54  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

by  the  name  of  mucus.  Examine  in  a  microscope  a  little- 
of  the  mucus,  and  you  will  find  it  made  up  of  minute  balls 
of  transparent  jelly  with  a  granular  aspect,  technically 
called  "  exudation  globules,"  "  mucous  globules/'  and  "  pus 
globules,"  floating  q[uite  free,  and  rolling  over  and  over 
without  any  tendency  to  adhere  together.  Tiiey  are  young 
cells,  or  rather  nuclei.  They  are  the  forms  assumed  by  all 
liquid  living  material  which  under  the  influence  of  life  is^ 
being  transformed  into  a  solid  ;  they  are  infant  tissue 
strangled  in  its  birth.  Instead  of  uniting  into  a  continuous 
web  to  clothe  with  epithelium  the  surface  of  the  membrane, 
they  float  off"  helpless  from  deficient  vitality.  The  business 
of  mucous  membranes  is  to  be  covered  with  epithelium, 
not  to  throw  off"  mucus;  and  when  they  are  doing  the 
latter  they  are  so  far  forth  in  a  state  of  diminished  life.' 

Or  there  may  be  a  pharyngeal  abscess,  or  a  quinsy. 

Disorders  of  motility  and  sensation  will  be  discussed  in 
Chapter  X. 

Beyond  what  the  eye  sees  the  nose  makes  its  note  when 
the  oral  cavity  is  examined. 

Smell. — The  breath  may  be  offensive  from  articles  of  food,^ 
as  the  onion,  or  garlic.  Or  decomposing  food  may  be  lodged 
amidst  the  teeth,  or  the  teeth  may  be  carious.  Or  there 
may  be  foul  ulcei's  causing  a  smell.  Or  the  metallic  smell 
and  taste  of  spongy  gums,  especially  if  due  to  mercury,  may 
be  present.  Or  the  breath  may  tell  of  alcoholics  recently 
taken;  or  that  stale  offensive  breath  of  the  drinker  ma^'- 
testify  to  excess,  however  voluble  and  solemn  the  protest  that 
such  is  not  the  case.  Then  the  breath  is  habitually  tainted 
with  some  persons,  while  in  others  it  is  only  off'ensive  in  times 
of  mental  worry,or  from  indigestion;  or  maybe  both  combined 
when  the  breath  is  very  disagreeable.  The  offensive  breath 
of  ozcena,  of  gangrene  of  the  lung,  and  foetid  bronchitis — due 
to  changes  in  the  fluid  in  bronchiectasis — is  known  to  all. 

Having  made  the  scrutiny  of  the  tongue,  the  next  thing 
to  be  observed  is  the  respiration. 


CHAPTER  IV. 

THE   RESPIRATION. 

The  respiration  is  worthy  of  stud}^  as  from  it  much  may- 
be learned.  For  instance,  a  patient  is  found  with  a  loud 
mitral  murmur,  maybe  regurgitant,  or  more  probably 
stenotic.  The  loudness  of  the  murmur  carries  with  it 
no  measure  of  the  extent  of  the  mischief;  for  that  we 
have  to  fall  back  upon  the  physiological  factor.  What  is 
the  effect  upon  the  respiration  ?  That  is  the  test  !  Does 
the  patient  breathe  calmly  ;  is  the  breathing  accelerated,  or 
distinctly  embarrassed  by  effort,  or  not  ?  If  the  patient 
breathe  calmly  when  at  rest,  and  there  is  no  unwonted 
effect  produced  upon  the  respiration  by  effort,  then  there 
is  but  a  slight  lesion  ;  if,  indeed,  there  be  any  at  all.  The 
murmur  may  be  entirely  free  from  any  sinister  indications. 

The  respiration  may  be  normal,  or  it  may  be  rapid,  or  it 
may  be  laboured. 

Rapid  Respiration. — The  thorax  of  an  ordinary  man  con- 
tains 250  cubic  inches  of  air,  known  as  '  the  residual  air.' 
In  the  act  of  respiration  so  much  air  is  expired,  and  so  much 
external  air  is  inspired.  The  expired  air  contains  more 
carbonic  acid  and  less  oxygen  than  the  outside  air.  About 
twenty-six  cubic  inches  of  air  are  taken  in,  and  given  out, 
at  each  respiratory  act.  The  normal  rate  of  inspiration  is 
about  eighteen  times  per  minute.  There  is  a  reservoir  of 
air  in  the  lungs  by  which  the  chemical  interchanges  can  be 
carried  on  while  the  breath  is  held,  as  in  diving.  To  hold 
the  breath  for  one  minute  is  no  pleasant  feat,  but  the  Indian 


56  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

pearl-diver  can  keep  under  water  for  a  mucli  longer  period. 
Four  minutes'  immersion,  and  the  person  is  dead,  as  a  rule. 
The  breath  can  be  held  so  long  as  such  interchanges  can  be 
carried  on  as  fairly  depurate  the  blood  of  its  carbonic-acid 
gas ;  when  the  carbonic  acid  in  the  blood  reaches  a  certain 
point,  the  respiratory  centre  flashes  out  an  efferent  message 
to  the  muscles  of  inspiration,  and  they  respond.  Men  under 
torture  which  they  knew  was  meant  to  be  continued  to 
death,  have  tried  to  kill  themselves  by  holding  the  breath ; 
but  they  have  never  succeeded.  In  the  drowning  person 
this  involuntary  respiration  draws  a  quantity  of  water  into 
the  air-passages  ;  and  probably  repeated  respiratory  acts, 
under  the  imperious  dictates  of  the  respiratory  centre,  fill 
the  thorax  with  water  till  the  body  loses  its  buoyancy  and 
sinks. 

When  from  any  reason  the  chemical  interchanges  are 
insufficient  to  depurate  the  blood  of  its  carbonic  acid,  then 
the  accumulation  of  this  carbonic  acid  excites  the  respira- 
tory centre,  and  violent  respiratory  efforts  are  made ;  until, 
by  increased  respiration,  the  residual  air  is  sufficiently 
purified,  so  that  the  normal  interchanges  are  regained. 
Thus  after  holding  the  breath  a  few  deep  inspirations  are 
necessitated,  after  which  all  is  once  more  calm.  If  the 
respiration  be  excited  by  a  more  prolonged  demand,  as  a 
sharp  run,  then  a  longer  time  of  exalted  respiration  is 
required  for  the  normal  state  to  be  regained.  Consequently, 
when  the  thoracic  space  is  impaired,  as  by  pneumonia  or 
congestion  of  the  lung,  the  diminished  residual  air  requires 
more  frequently  '  the  tidal  air  '  to  maintain  its  purity;  and 
so  the  breathing  is  accelerated,  or  rapid. 

Consequently  accelerated  respiration  tells  of  excess  of  (1) 
blood;  (2)  connective-tissue  ;  (3)  water,  in  oedema  of  the  lung 
or  pleuritic  effusion;  (4)  pus  in  empyema;  (5)  a  morbid 
growth  ;  (6)  air  in  pneumothorax  ;  or  (7)  mucus  in  bronchial 
catarrh.  (Air  in  emphysema  involves  rather  another  modi- 
fication to  be  discussed  shortly.)    Of  course  the  mere  increase 


THE  RESPIRA  TION.  57 

of  rapidity  cannot  indicate  the  nature  of  the  cause  of  it. 
Excess  of  blood  may  be  due  to  inflammation  of  the  lungs  ; 
to  congestion  of  the  lungs  (localized) ;  or  to  fulness  of  the 
pulmonic  circulation  from  a  mitral  lesion.  Excess  of  con- 
nective-tissue may  occur  as  fibrosis,  or  as  pulmonary  tuber- 
culosis. Excess  of  water  is  found  in  <jedema  of  lungs,  or 
effusion  into  the  pleural  cavities  ;  or  maybe  into  the  peri- 
cardium. Excess  of  pus  is  usually  found  in  empyema,  but 
an  abscess  might  cause  it.  A  morbid  growth,  as  a  tumour, 
or  a  cancer,  will  accelerate  the  respiration  in  proportion  as 
its  size  impinges  upon  the  thoracic  space.  Air  elsewhere 
than  in  the  air-passages  will  produce  the  same  result  of 
diminution  of  the  thoracic  space.  Catarrh  of  the  bronchial 
lining  membrane  will  also  accelerate  the  respiration  by 
diminishing  the  lumen  of  the  air-tubes  ;  also  blocking  some 
of  them  temporarily. 

Careful  estimation  of  the  rate  of  respiration  will  often 
materially  aid  the  observer  to  read  the  physical  signs  ai'ight. 
Especially  is  this  the  case  when  the  peccant  matter  is  either 
disseminated  over  the  lungs,  as  in  general  fibrosis,  or  the 
neoplasm  is  too  deep-seated  to  affect  the  percussion-note; 
or  there  are  internal  cavities,  or  bronchial  dilatations  ;  or 
there  is  a  large  accumulation  of  mucus  in  the  air-passages. 
Indeed,  the  rapidity  of  the  respiration  will  tell  him  more 
exactly  the  ainou)it  of  the  disturbing  cause  than  will  per- 
cussion or  auscultation  at  times.  He  must,  however,  com- 
pare the  ratio  of  the  respiration  to  the  pulse,  which  is 
normally  1  to  4 ;  the  first  being  18  and  the  latter  72.  It  is 
well,  indeed,  to  do  this  habitually  ;  and  if  such  practice 
obtained  many  an  error  would  be  avoided.  If  the  pulse  and 
the  respiration  both  be  high,  then  there  is  either  some  febrile 
condition  or  nervous  excitement ;  something  which  affects 
both  alike,  and  probably  the  temperature  too.  (But  of 
this  last  anon.)  Such  use  of  the  watch  will  usually  tell 
how  a  case  is  going  on.  If  the  breathing  becomes  accelerated 
out  of  proportion  to  the  pulse  rate,  then  it  is  high  time   to 


58  PHYSIOLOGICAL  FACTOR  LN  DIAGNOSIS. 

look  for  something  ;  and  '  something  '  will  usually  be  found. 
Say  the  patient  is  in  bed  with  mitral  disease,  for  instance, 
and  the  respiration  rises :  then  there  is  some  special  cause 
of  diminution  of  the  thoracic  space,  which  will  probably 
be  found  to  be  congestion  of  the  bases  of  the  lung,  mostl}'- 
at  the  back — the  dependent  part.  If  there  be  dropsy 
present,  it  may  be  oedema.  The  use  of  the  watch  will  often 
put  the  medical  man  on  his  guard,  and  make  him  examine 
the  chest  when  otherwise  there  might  appear  to  be  no 
especial  call  to  do  so.  Also  it  will  often  relieve  him,  and 
still  more  the  patient,  from  examination  which  is  superfluous, 
troublesome,  and  yet  negative  of  result.  It  may  happen 
that  a  fidgety  patient  (very  likely  a  medical  man,  who 
makes  a  very  trying  patient  as  a  rule)  may  like  a  physical 
examination,  and  be  dissatisfied  without  it ;  but  there  are 
others  who  resent  beinw  disturbed  without  sufficient  reason. 
To  take  the  ratio  of  the  respiration  and  the  pulse  will  often,, 
indeed  commonly,  tell  whether  a  physical  examination  be 
required  ;  or  may  safely  be  dispensed  with.  If  the  respira- 
tion has  been  accelerated  and  f\\lls,  then  it  is  fairly  clear 
the  infringement  upon  the  thoracic  space  is  diminishing. 

The  rapid  breathing  may  be  shallow,  Avith  little  respira- 
tory movement  ;  this  is  found  with  nervous  states,  and  in 
some  forms  of  phthisis.  Usually  in  the  latter  case  there  is 
no  great  impairment  of  the  thoracic  space  demanding  accele- 
rated breathing  ;  it  is  rather  nervous  than  of  organic  origin 
in  many  instances,  even  when  some  consolidation  is  present. 

Deep  Respiration. — This  is  linked  with  other  conditions 
within  the  thorax.  In  emphysema  the  patient  will  be  seen 
fixing  the  shoulders,  so  as  to  enable  the  accessory  muscles 
of  inspiration  to  act  more  efficiently  ;  and  then  the  sterno- 
niastoid  muscles  will  be  seen  to  stand  out  like  cords,  rhyth- 
mically as  each  inspiration  is  accomplished.  If  the  patient 
be  lying  in  bed,  the  character  of  the  respiration  is  very 
instructive.  The  muscles  at  tiie  top  of  the  thoracic  case 
are  seen  to  contract  powerfull}',  while  the  abdomen  rises. 


THE  RESPIRA  TION.  59 

The  neck-muscles  drag  up  the  comparatively  immovable 
and  rigid  thoracic  case,  while  the  diaphragm  descends.  The 
inspiration  here  is  the  antithesis  of  the  swell  and  fall  of  a 
woman's  bosom.  (Why  a  woman's  bosom  ?  an  unreflecting 
reader  may  ask.  Because  a  woman's  thoracic  space  is  liable 
to  be  physiologically  impaired  from  below  by  a  gravid 
uterus ;  and  when  the  full  term  of  pregnancy  is  being 
reached,  her  respiration  is  almost  entirely  thoracic.) 

In  asthma  the  same  laboured  respiration  may  be  seen. 
It  may  be  cardiac  asthma  when  the  breathing  is  both 
laboured  and  rapid;  or  at  other  times,  and  more  commonly, 
laboured  and  deep;  or  it  may  be  true  spasmodic  asthma, 
with  diminution  of  the  lumen  of  the  air- passages.  When  the 
air  has  to  be  forcibly  drawn  through  narrowed  air-tubes, 
then  the  breathing  cannot  well  be  rapid;  it  must  be  deep. 
Rapid  breathing  is  incompatible  with  obstructed  air-passages. 
They,  at  least,  are  unimpaired  in  rapid  respiration  ! 

The  study  of  the  character  of  the  respiration  in  each  case 
of  thoracic  trouble  is  highly  interesting,  as  well  as  instruc- 
tive. It  is  most  easily  carried  out  in  large  wards,  where 
various  forms  of  thoracic  disease  are  lying  side  by  side,  when 
the  character  of  the  respiration  in  different  forms  becomes 
very  manifest ;  and  is,  almost,  in  itself  sufficient  to  indicate 
the  maladj'-,  or  the  leading  factor  in  a  complex  case. 

Nor  must  the  reader.be  under  the  impression  that  the 
typical  '  barrel-shaped  '  thorax  of  emphysema  is  alone  com- 
patible with  it.  He  will  often  be  surprised  to  find  extensive 
emphysema  with  the  flat  chest  supposed  to  be  peculiar  to 
phthisis — the  compensatory  emphysema  of  Niemeyer. 

The  diaphragmatic  breathing  will  depress  all  the  abdominal 
viscera  from  the  violent  contraction  of  the  diaphragm.  Con- 
sequently the  liver  is  displaced  downwards, and  this  displaced 
liver  might  easily  be  mistaken  for  an  enlarged  liver  by  a 
careless  observer.  The  emphysematous  lungs  overlap  the 
heart,  and  abolish  the  area  of  cardiac  dulness  more  or  less 
completely  ;    sometimes  entirel^^      Abolition  of  the  heart- 


6o  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

dulness,  and  diminution  of  the  liver-dulness  till  it  is  only 
found  at  tlie  very  edge  of  the  ribs,  are  indicative  of  con6rmed 
emphysenna. 

(Emphysema  of  the  anterior  fringe  of  the  lungs  is  very 
common  in  athletes,  and  those  who  have  been  subject  to 
efforts  at  once  severe  and  prolonged.  Sometimes  the 
emphysema  becomes  more  general ;  this  may  be  termed 
'the  athlete's  chest.'  It  is  most  commonly  found  in  rather 
undersized  men,  where  pluck  has  tried  to  make  up  for 
muscular  power.  In  time  the  whilom  athlete  becomes 
comparatively  '  broken-winded  '  from  emphysema,  and  is 
less  equal  to  effort  than  an  ordinary  person.  This  is  a 
matter  the  devotees  of  athletics  had  better  take  to  heart. 
Emphysema  from  over-effort  is  as  surely  a  clinical  fact, 
as  that  aortic  valvulitis  is  causally  linked  with  prolonged 
severe  muscular  effort.) 

Effect  of  Effort. — In  relation  to  the  matter  of  observation 
of  the  respiration,  it  is  most  important  often  to  note  the 
effect  of  effort.  That  we  possess  much  spare  lung  for 
occasions — without  which  any  unusual  effort  would  be 
impossible — is  well  known.  Consequently  in  many  cases 
the  respiration  is  calm  while  quiet  is  maintained  ;  but  any 
effort  reveals  thoracic  impairment  by  the  respiration  becom- 
ing quick  or  laboured.  Here  there  is  not  enough  of  mischief 
to  affect  the  respiration  while  the  patient  is  quiet ;  but  it 
becomes  palpable  enough  when  any  exertion  is  attempted. 
The  circumstances  which  give  rise  to  it  are  exactly  those 
which  affect  the  respiration  while  quiet,  only  not  so  pro- 
nounced. 

That  such  should  be  the  case  with  disease  of  the  respi- 
ratory organs  is  readily  seen.  Nor  is  it  difficult  to  com- 
prehend why  effort  should  produce  shortness  of  breath  in 
valvular  disease  of  the  heart,  especially  mitral  disease ;  the 
dam  of  blood  at  that  point  is  increased  on  effort,  and  so 
the  pulmonic  circulation  is  gorged,  and  thus  the  thoracic 
space  is  diminished  for  respiratory  purposes.     There  is  one 


THE  RESPIRATION.  6i. 

other  condition  not  so  apparent  where  the  effect  of  effort  is 
to  produce  breathlessness,  and  that  is  in  pronounced  condi- 
tions of  anseraia.  There  the  red  blood-corpuscles  are  sufficient 
for  the  requirements  of  the  sj^stem  in  quiet ;  but  effort  pro- 
duces breathlessness,  compelling  quiet. 

Nocturnal  Dyspnoea. — In  certain  morbid  states  the  patient 
is  awakened  out  of  sleep  by  a  craving  for  air.  In  my  own 
experience  this  occurs  mainly  in  cases  of  chronic  renal 
disease ;  still  more  when  to  such  renal  condition  is  added 
the  effects  of  soporifics.  Basham  called  them  *  inexplicable 
dyspnoea.'  What  it  is  which  palsies  the  respiratory  centre 
in  chronic  Bright's  disease  is  not  known ;  but  something 
does.  The  elimination  of  carbonic  acid  is  checked  until  it 
accumulates  to  the  extent  of  rousing  the  respiratory  centre 
to  extensive  discharges,  setting  the  accessory  muscles  of 
respiration  into  action ;  with  the  effect  that  the  powerful 
inspirations  rapidly  get  rid  of  the  excess  of  carbonic  gas- 
in  the  blood  :  after  which  the  breathing  becomes  calm,  and 
the  patient,  ere  long,  drops  off  to  sleep.  When  to  this  morbid 
agent,  be  it  what  it  may,  is  added  the  action  of  an  hypnotic, 
such  loss  of  sensibility  in  the  respiratory  centres  is  readily 
intelligible.  This  nocturnal  dyspnoea  is  allied  in  nature  to 
the  paroxysms  of  palpitation,  by  which  some  persons  are 
awakened  when  the  heart  is  not  in  its  integrity.  Distension 
of  the  cavities,  usually  the  right,  goes  on  until  it  provokes 
active  discharges  in  the  cardiac  ganglia  (these  and  the  respi- 
ratory centre  are  the  rhythmically  discharging  centres  of 
the  organism,  see,  *  The  Antagonism  of  Therapeutic  Agents, 
and  what  it  Teaches,'  p.  60),  which  set  up  pronounced 
muscular  contractions  ;  and  then  palpitation  is  experienced. 
Or  the  patient  may  awake,  feeling  as  if  going  to  die,  the 
heart's  action  being  imperceptible  from  a  marked  fall  in  the 
action  of  the  heart  in  sleep :  indeed  fainting,  or  syncope,  in 
sleep  is  not  unknown.  It  is  well  to  ponder  over  this  noc- 
turnal dyspnoea  in  relation  to  the  two  conditions — cardiac 
dyspnoea,  or  cardiac  asthma,  and  Cheyne-Stokes  respiration. 


€2  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

Cardiac  Astlima. — The  occurrence  of  cardiac  asthma  in  the 
night  not  only  alarms  the  patient,  but  also  those  in  attend- 
ance upon   him.     It  is  usually  seen  with  mitral  disease,  or 
failure  of  the  muscular  walls  of  the  heart.     The  patient  may- 
have  been  sleeping  soundly,  when  he  awakens  up  suddenly 
with  much  embarrassment  of  the  respiration.     He  sits  up 
in  bed  gasping  for  breath,  perhaps  asking  to  be  fanned ;  or 
he  clutches  the  bedclothes  convulsively,  to  fix  the  arms  and 
shoulders  so  as  to  bring  the  pectoral  muscles  into  play  as 
respiratory  accessories ;  and  sits  there,  '  breathing  for  dear 
life.'     The  countenance  tells  of  the  distress  he  is  enduring:. 
The  heart  may  be  palpitating  forcibly,  telling  of  the  energy 
of  the  contractions  of  the  right  ventricle — for  here  the  right 
side  of  the  heart  is  greatly  distended.     After  a  time  the 
distended    muscular  wall  recovers   itself,  and  the  patient, 
exhausted  by  the  effort,  falls  back  to  sleep,  or  perhaps  sits 
propped  up  ;  thankful  the  worst  of  the  paroxj'sm  is  over, 
and  yet  far  from  being  at  ease  !     If  the  muscular  fibres  are 
free  from  degeneration  it  is  surprising  what  the  patient  will 
endure  and  survive.     He  is  quite  sure  another  attack  will 
finish  him  ;  but  he  survives  another,  and  yet  another.     I 
remember  a  patient  in  Westmoreland,  a  quarry-mason,  with 
a  mitral  lesion,  to  whom  I  was  often  summoned  in  the  winter' 
of  1868-69,  in  severe  paroxysms  of  cardiac  asthma,  which 
lasted  usually  some  three  hours.      He   lived   three   miles 
away,  and  the  attacks  came  on  about  two  in  the  morning. 
So  severe  indeed  were  they,  in  spite  of  hot  poultices  back 
and  front,  hot  spirits  and  water,  ammonia,  nux  vomica,  and 
digitalis  (as  well  as   a   steady  course  of  digitalis),  that  I 
frequently  got  out  my  lancet-case,  and  stood  lancet  in  hand, 
ready  to  open  a  vein  and  relieve  the   right   ventricle  ;  if 
relief  was  not  attained  by  the  other  measures.     This,  how- 
ever, was  never  actually  required.     As  spring  went  on  the 
attacks  ceased,  the  general   condition  improved  from  the 
enforced  rest,  and  the  patient  went  back  to  work  ;  though 
past  middle  age.     Ten  years  later  he  was  working  away  ; 


THE  RESPIRATION.  63 

never  being  laid  up  till  the  severe  winter  of  1880-81  gave 
him  an  acute  attack  of  bronchitis,  to  which  he  succumbed. 
These  paroxj^sms  are  very  painful  to  witness ;  they  are  very 
exhausting,  and  if  the  medical  man  be  either  timid  in  his 
measures  or  inattentive  to  the  indications,  are  fraught  with 
great  danger.  These  attacks  are  often  strictly  related  to  the 
patient's  supper  ;  a  weight  in  the  stomach,  or  a  quantity  of 
gas  in  it,  pressing  upon  the  distended  right  ventricle  through 
the  thin  aponeurotic  portion  of  the  diaphragm,  impedes  its 
action,and  pulmonary  congestion  with  acute  distension  of  the 
right  heart  follows;  or  the  patient  gets  up  to  stool,  and 
becoming  chilled  on  getting  into  the  cold  bed,  a  paroxysm 
of  dyspnoea  is  set  up  ;  and  this  may  occur  though  a  fairly 
^ood  fire  is  maintained,  especially  in  winter.  It  may  occur 
at  other  times  than  in  the  small  hours  of  the  morning  ;  but 
these  are  the  ordinary  times  at  which  attacks  of  cardiac 
asthma  manifest  themselves.  The  injected  features  dis- 
tinguish attacks  of  cardiac  asthma  from  spasmodic  asthma  ; 
and,  as  a  rule,  the  patients  are  more  seriously  ill,  though 
perhaps  not  more  distressed  ! 

Cheyne-Stokes  Respiration. — This  is  a  curious  rise  and  fall 
in  the  respiration.  Stokes  describes  it  graphically  (using 
'  apnoea '  in  a  sense  the  opposite  of  the  '  apncea '  of  the 
modern  physiologist)  :  '  It  consists  in  the  occurrence  of  a 
series  of  inspirations,  increasing  to  a  maximum  ;  and  then 
declining  in  force  and  length,  until  a  state  of  apparent 
apnoea  is  established.  In  this  condition  the  patient  may 
remain  for  such  a  length  of  time  as  to  make  his  attendants 
believe  that  he  is  dead ;  when  a  low  inspiration,  followed 
by  one  more  decided,  marks  the  commencement  of  a  new 
ascending  and  then  descending  series  of  inspirations.  This 
symptom,  as  occurring  in  its  highest  degree,  I  have  only 
seen  during  a  few  weeks  previous  to  the  death  of  the 
patient.  The  decline  in  the  length  and  force  of  the  respi- 
rations is  as  regular  and  remarkable  as  their  progressive 
increase.     The  inspirations  become  each  one  less  deep  than 


64  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

the  preceding,  until  tbey  are  all  but  imperceptible ;  and  then 
the  state  of  apparent  apnoea  occurs.  This  is  at  last  broken 
by  the  faintest  possible  inspiration  :  the  next  effort  is  a  little 
stronger,  until,  so  to  speak,  the  paroxysm  of  breathing  is  at 
its  height ;  again  to  subside  by  a  descending  scale  !  There 
is,  indeed,  an  ebb  and  flow  in  the  inspiration.  An  ebb  till 
the  accumulation  of  carbonic  acid  in  the  blood  wakens  up 
the  respiratory  centre,  and  the  blood  is  fairly  depurated  ; 
then  the  breathinor  falls  again,  and  a  re-accumulation  of 
carbonic  acid  follows :  and  this  recurs  again  and  again. 
At  one  time  this  rhj^thmic  respiratory  derangement  was 
held  to  belong  to  the  fatty  heait  solely;  but  it  is  now 
recognised  as  occurring  under  a  variety  of  circumstances. 
Personally  I  first  saw  it  in  a  case  of  apoplexy  (where  the 
cycle  of  ebb  and  flow  covered  fifteen  inspirations)  ;  next  in 
a  case  of  primary  tricuspid  disease.  It  belongs  to  vascular 
conditions,  and  to  affections  of  the  cerebral  hemispheres 
mainly.     It  is  also  found  in  uraemia. 

Both  nocturnal  dyspnoea  and  Chejme-Stokes  respiration 
are  instances  of  failure  of  the  respiratory  centre,  with 
accumulation  of  carbonic  acid  in  the  blood,  which  will  well 
repay  thought.  They  tell  that  stimulants  to  the  respiratory 
centre  are  indicated.  Nocturnal  dyspnoea  is  a  less  grave 
condition  than  cardiac  asthma,  and  if  comparatively  quickly 
over.  It  is  also  free  from  the  grim  associations  of  the 
Cheyne-Stokes  phenomenon,  which  is  '  a  very  bad  sign  *  in 
any  case. 

Sighing  Respiration. — This  peculiarity  has  been  termed 
sighing,  or  suspirious  respiration.  We  sigh  when  abstracted 
in  thought,  or  after  the  relief  of  suspense.  It  is  a  long 
breath  indicating  the  stimulus  of  excess  of  carbonic  acid  in 
the  respiratory  centre.  It  is  held  to  be  suggestive  of  fatty 
degeneration  of  the  heart,  and  is  seen  maikedly  in  angina. 
'Some  of  the  worst  cases  I  have  seen  have  been  those  in 
which  the  only  lesion  that  could  be  fairly  presumed  to  exist 
was  fatty  or  other  degeneration  of  the  fibre  of  the  heart. 


THE  RESPIRATION.  65 

sometimes  with,  sometimes  without,  direct  evidence  of 
moderate  or  slight  dilatation  of  the  left  ventricle '  (W.  T. 
Gairdner).  Sighing  or  suspirious  respiration  should  always 
direct  the  observer's  attention  to  the  condition  of  the  heart 
and  arteries. 

Stridor. — Noisy,  coarse,  or  shrill  inspiration  suggests  some 
difficulty  at  the  laryngeal  oritice.  It  may  be  due  to  spasm 
in  '  crowing  croup  '  (laryngismus  stridulus),  or  to  genuine 
croup ;  to  oedema  of  the  epiglottis,  or  acute  laryngitis,  as  a 
passing  condition  ;  or  to  chronic  change  in  the  structure  of 
the  larynx;  or  to  polypi,  as  a  more  permanent  state,  with 
paroxysms  of  acute  aggravation.  False  croup  gives  the 
ringing  cough,  not  the  croupy  cough  and  respiration  of  true 
croup;  it  is,  moreover,  a  condition  infinitely  less  grave  than 
true  croup,  and  occurs  at  short  intervals,  which  true  croup 
does  not.  Yet  the  ear  has  to  be  trained  to  recognise  the 
sounds  of  false  croup.  In  chronic  disease  of  the  larynx  the 
voice  is  more  suggestive  than  the  respiration  ;  though  there 
is  stridulous  respiration,  with  harsh  or  barking  cough,  and 
paroxysms  of  dyspnoea,  at  intervals. 

Dyspnoea. — This  is  found  with  many  different  maladies. 
As  a  grave  symptom  in  thoracic  conditions,  involving 
impairment  of  the  thoracic  space,  it  has  been  discussed 
before  (p.  56).  It  is  found,  however,  with  laryngeal  disease, 
with  pressure  upon  the  trachea  (usually  an  aneurysm),  cancer 
extending  from  the  oesophagus,  or  an  enlarged  gland.  When 
one  or  other  bronchus  ordy  is  pressed  upon,  then  the  dyspnoea 
is  only  marked  on  exertion. 

When  the  lumen  of  the  air- tubes  is  diminished  it  follows, 
as  in  spasmodic  asthma.  Frequently  the  spasmodic  asthma 
has  this  association:  A  cold  with  swelling  of  the  mucous 
lining  of  the  air-tubes,  by  which  the  breathing  is  rendered 
hard ;  then  the  irritation  of  this  dry  tumid  membrane  sets 
up  spasm  of  the  bronchial  muscular  fibre,  by  which  the 
condition  of  shortness  of  breath  is  accentuated  with  distinct 
asthma,  taxing  the  powers   very  plainly.      Dyspnoea,  too, 

5 


66  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


{ 


"belongs  to  bronchitis  where  all  the  tubes  are  lessened  as  to 
their  lumen,  and  where  many  are  occluded  with  phlegm.  In 
chronic  bronchitis,  with  emphysema,  there  is  dyspnoea  on 
effort,  with  shortness  of  breath  always.  In  emphysema 
uncomplicated  with  chronic  bronchitis  such  permanent 
embarrassment  is  found  with  acute  paroxysms,  due  to 
spasm  of  the  circular  fibre  of  the  air-passages. 

The  following  case  is  full  of  interest :  A  well-grown  girl, 
with  an  excellent  thorax,  was  brought  to  me  for  suspected 
heart-mischief;  as  she  was  quickly  out  of  breath  on  effort. 
The  heart  was  all  right.  The  chest  was  perfectly  resonant. 
But  on  auscultation  the  respiratory  murmur  was  deficient 
in  the  riofht  luno:,  all  over  it.  It  was  found  that  there  was 
little  movement  of  the  right  half  of  the  thorax  in  respira- 
tion. It  was  clear  the  trouble  affected  the  whole  lung.  It 
must  be  pressure  on  the  right  bronchus.  A  limited  area 
of  percussion-dulness  was  found  over  this  bronchus.  It  was 
an  enlarged  bronchial  gland  resultant  upon  an  acute,  but 
not  severe  bronchial  attack.  The  diagnosis  of  enlarged 
bronchial  gland  was  no  feat  in  diagnosis ;  it  was  simply 
unavoidable,  except  by  gross  carelessness.  She  has  improved 
very  slowly. 

Dyspnoea  may  belong  to  the  diaphragm,  as  paralysis  of 
that  muscle,  or  fatty  degeneration  of  it,  along  with  a  fatty 
heart;  or  in  conditions  of  malnutrition  of  the  heart  and 
diaphragm,  which  I  have  called  '  heart-starvation,'  not 
uncommon  in  grave  conditions  of  mal-assimilation.  In 
rheumatism  or  gouty  inflammation  of  the  serous  coverings 
of  the  diaphragm  a  condition  of  embarrassed  inspiration  is 
found,  from  defective  or  arrested  (by  the  pain  it  produces) 
action  of  the  muscle.  Then  dyspnoea  may  be  due  to  some 
condition  outside  the  thorax.  Whenever  the  descent  of  the 
diaphragm  is  impeded,  then  dyspnoea  follows.  Thus  when 
the  uterus  rises  high  in  the  last  weeks  of  pregnancy  the 
breathing  is  embarrassed.  In  large  ovarian  cysts  the  dia- 
phragm may  be  so  pushed  up  as  to  be  all  but  inoperative 


THE  RESPIRATION.  67 

in  inspiration,  and  the  respiration  be  altogether  thoracic. 
An  enlarged  liver  will  produce  the  same  result  as  the 
amyloid  liver  of  youth,  and  the  cancerous  liver  of  age.  Or 
■ascites  may  embarrass  the  diaphragm.  Flatulent  distension 
of  the  intestines  is  often  a  great  source  of  distress  to  those 
afflicted  with  a  weak  heart,  and  especially  when  the  right 
heart  is  severely  taxed.  Emphysematous  patients  often 
suffer  much  from  flatulent  distension  interferinof  with  the 
action  of  the  diaphragm. 

Cough. — A  cough  is  an  involuntary  forced  expiration ;  com- 
monly excited  by  the  presence  of  some  irritant  cause  in 
the  air-passages,  which  is  removed  by  the  cough.  Some- 
times one  cough  is  enough  for  this  end ;  sometimes  a 
paroxysm  of  repeated  coughs  is  necessary  for  its  removal. 
Sometimes  the  irritant  matter  is  removable  by  cough,  some- 
times not.  When  a  crumb  *  goes  the  wrong  way,'  cough  is 
successful  in  getting  rid  of  it.  When  a  softening  tubercular 
mass  is  the  cause,  then  the  cough  is  useless — until  the  soften- 
ing has  reached  that  point  that  the  matter  can  be  expec- 
torated. Each  is  a  foreign  body,  like  '  the  thorn  of  Van 
Helmont.'  (The  thorn  (I'epine)  of  Van  Helmont  is  an 
expression  now  almost  forgotten.  Trousseau  uses  it.  A 
foreign  body — that  is,  an  abnormal  substance,  whether 
introduced  from  without  or  produced  from  within — is  an 
irritant  to  the  tissues  around  it,  like  '  a  thorn  '  in  the  flesh.) 
Thus  we  get  cough  from  a  source  of  irritation  in  the  air- 
passages,  whether  drawn  in  by  inspiration,  as  smoke  ;  or 
produced  within,  as  bronchial  mucus.  A  softening  mass  of 
tubercle  excites  cough  ;  or  fulness  of  the  pulmonary  vessels, 
as  the  '  heart-cough  '  of  mitral  valvulitis.  The  irritation  may 
exist  elsewhere.  A  *  stomach  cough '  is  common  in  indi- 
gestion ;  a  '  liver-cough '  is  not  unknown  :  while  the  '  cradle 
cough '  of  pregnancy  is  familiar  to  all.  An  '  ear-cough ' 
also  is  generally  recognised.  A  dry  cough  is  excited  by 
worms,  or  by  dentition,  or  some  central  brain  aff'ection. 
The  cough  excited  by  a  long  uvula  has  often  been  mistaken 

5—2 


68  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

for  the  cough  of  early  phthisis.  Children  and  young  persons, 
mostly  girls,  are  liable  to  a  neurosal  cough.  Sometimes  it 
is  loud,  even  brazen,  like  the  cough  of  an  aneurysm  pressing 
on  the  recurrent  laryngeal  nerve  ;  more  commonly  it  is  the 
little  '  hemming  '  cough  of  early  phthisis.  This  last  is  at 
times  almost  incessant,  and  causes  great  alarm  to  the  patient's 
friends.  Then  there  is  the  cough  of  chill  blood  passing  into 
the  lungs,  experienced  on  getting  into  a  cold  bed,  so  trouble- 
some with  elderly  persons  who  have  morbid  changes  in  their 
respiratory  organs,  or  their  circulation.  Also  the  cough  of 
getting  out  of  a  warm  bed  on  a  cold  morning.  This  usually 
dislodges  some  of  the  mucus  which  has  gathered  in  the 
night,  and  repeated  cough  gets  up  a  quantity  of  mucus 
often  dark-coloured  from  carbon.  This  is  usual  in  persons 
with  some  bronchial  catarrh,  and  is  spoken  of  as  '  morning 
cough.'  In  disease  of  the  larynx  and  trachea  the  cough  is 
shrill  or  hoarse,  or  barking,  while  the  '  croupy  '  cough  of 
children  is  well  known.  The  dry,  irritant  cough  of  the 
first  stage  of  bronchitis,  when  the  mucous  membrane  is 
tumid,  contrasts  with  the  moist  cough  of  the  second  stage, 
when  the  secretion  is  free.  A  dry  cough  may  indicate  a 
thoracic  or  a  non-thoracic  cause.  A  moist  cough  is  asso- 
ciated with  conditions  which  are  intra-thoracic,  and  which 
produce  fluid  in  the  air-passages,  as  bronchitis  (where  the 
moist  cough  succeeds  the  dry  as  the  case  moves  on)  ;  secretion 
in  bronchiectasis  or  cavities  ;  oedema  of  the  lung  ;  the  clearing 
up  of  pneumonia  with  grey  expectoration ;  the  florid  sputum 
of  earlier  pneumonia;  the  prune-juice  of  broncho-pneumonia ; 
the  blood  of  vascular  congestion,  whether  general  (mitral)  or 
local  (in  patches  of  consolidation). 

The  cough  may  be  very  exhausting  at  times,  as  in  soften- 
ing tubercle,  the  patient  being  bedewed  with  perspiration. 
It  may  be  prolonged  when  the  firm  walls  of  a  bronchial 
dilatation  in  a  cavity  resist  the  pressure  requisite  to  expel 
their  contents.  It  is  very  painful  in  cases  where  the  pleura 
is   inflamed.     Sometimes  it  is  most  troublesome  in  the  dav. 


THE  RESPIRATION.  69 

at  other  times  it  is  worst  in  the  night,  utterly  preventing 
sleep  in  some  cases,  while  dry  '  hemming  '  or  '  phthisacking ' 
neurosal  cough,  especially  in  children,  may  go  on  in  sleep,  the 
rest  being  unbroken  by  it. 

Hiccough. — This  is  a  troublesome  spasm  of  the  dia- 
phragm, frequently  seen,  and  without  significance.  It  lasts 
only  a  short  time.  But  when  it  is  due  to  gouty  inflam- 
mation of  the  serous  coverings  of  the  diaphragm,  it  is 
persistent.  As  the  trouble  spreads,  so  the  different  organs 
are  affected.  When  travelling  over  the  stomach,  there  is 
vomiting;  when  extending  over  the  abdominal  surface  of 
the  diaphragm,  '  hiccough  '  is  excited.  Persistent  hiccough 
in  advanced  life  has  always  been  regarded  as  fraught  with 
a  grave  prognosis.  Its  cause  may  be  encephalic,  and  not 
diaphragmatic.  In  pericarditis  the  phrenic  nerves,  espe- 
cially the  right  phrenic,  may  be  so  involved  as  to  cause 
severe  hiccough.  In  some  cases  this  may  extend  to  the 
length  of  paralysis  of  the  diaphragm,  with  falling  of  the 
abdomen  on  inspiration.  Hiccough  differs  from  cough,  in 
that  it  is  an  inspiratory,  not  an  expiratory  act. 

Whooping  Cough. — This  is  a  cough  sni  generis.  It  is  not 
connected  so  much  with  expiration  as  are  other  coughs,  but 
rather  with  inspiration,  '  The  coughing-fit  begins  with  a 
long-drawn,  clear,  piping  sound  (produced  as  the  air  is 
slowly  drawn  into  the  constricted  glottis).  Then  follows  a 
series  of  short,  rapidly  interrupted,  expiratory  coughs  (the 
air,  though  vigorously  expelled,  being  unable  to  force  open 
the  glottis  for  more  than  a  moment  at  a  time),  and  this  is 
succeeded  by  the  crowing,  long-drawn,  inspiratory  act.'  The 
*  whoop  '  tells  that  the  paroxysm  is  over.  Vomiting  is  a 
common  result ;  even  the  contents  of  the  bladder  or  bowels 
may  be  expelled,  or  prolapsus  ani  be  produced.  The  face 
is  blue  with  venous  blood,  and  effusions  of  blood  may  follow, 
either  outwardly  or  into  the  tissues.  The  child  dreads  the 
cough,  and  will  cling  to  anything  which  will  enable  it  to  fix: 
its  shoulders  to  cough.     After  the  true  cough  has  passed 


70  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

away,  an  imitative  cough  may  remain,  by  the  force  of  habit, 
for  some  considerable  time. 

Sneezing. — This  is  an  expiratory  act,  which  is  not  a  cough. 
It  is  caused  by  irritation  of  the  nasal  filaments  of  the  fifth 
pair.  A  cough  clears  the  air-passages  below  the  pharynx  ; 
a  sneeze  is  directed  at  the  nasal  passages.  In  a  sneeze  the 
outgoing  current  of  air  sweeps  those  portions  of  the  nasal 
cavities  which  lie  out  of  the  ordinary  air-currents,  and 
remove  the  offending  matter — when  so  removable.  In  a 
cold  affecting  the  nasal  portion  of  the  respiratory  tracts 
sneezing  is  usual.  At  other  times  sneezing  is  rather  a 
neurosis  connected  with  nazal  coryza,  and  may  be  very 
persistent. 

Position. — The  position  assumed  by  a  patient  in  reference 
to  his  breathing  is  highly  instructive.  He  lies  in  that  position 
which  enables  him  to  breathe  most  easil}-.  Probably  most 
people  sleep  on  their  right  side  rather  than  on  their  left ;  this 
is  due  to  the  liver,  which  is  most  out  of  the  way  of  the 
diaphragm  when  the  individual  is  on  the  right  side.  In 
some  cases  the  patient  can  only  sleep  propped  up,  or  sitting 
up  in  a  chair,  so  that  the  contents  of  the  abdomen  may  fall 
away  from  the  diaphragm.  This  matter  is  closely  linked 
with  orthopnoea. 

Another  matter  is  this :  the  side  which  is  undermost  is 
comparatively  at  rest.  Consequently  the  patient  gets  upon 
the  diseased  side  in  many  cases ;  indeed,  would  suffocate, 
or  feel  as  if  being  suffocated,  if  the  sound  side  were  under- 
most, and  so  acting  little.  In  congestion  of  one  lung  the 
patient  will  keep  on  the  affected  side.  When  the  con- 
gestion is  passing  away,  he  will  be  seen  to  turn  over  on 
the  other  side  for  a  time  at  intervals.  (This  is  a  little  matter 
not  unworthy  of  being  noted,  as  it  will  sometimes  enable 
the  observer  to  '  score.')  The  patient  will  seek  ease  indeed, 
each  according  to  his  own  peculiarities.  Speaking  of  pleurisy, 
Walshe  says : 

'  During  the  dry  and  plastic  stages,  the  patient  commonly 


THE  RESPIRATION.  71 

lies  on  the  sound  side  or  on  the  back.  I  have  seen  excep- 
tional individuals  lie  by  choice  on  the  diseased  side  to  con- 
trol motion  and  stifle  pain,  as  they  assured  me ;  generally 
speaking,  this  posture  increases  pain.  After  effusion  has 
occurred,  the  patient  lies  on  the  back,  on  the  affected  side, 
or  diagonally  between  both,  with  the  head  somewhat  raised.' 
He  may  lie  on  either  side  at  first,  according  as  ease  is 
attained ;  but  when  there  is  effusion,  he  does  not  lie  with 
the  affected  side  uppermost.  The  upper  lung  is  '  the  working 
lung  ;'  and  if  the  working  lung  be  compressed  by  an  effusion, 
the  breathing  would  be  too  embarrassed  to  be  borne  or 
tolerated.  With  the  effusion,  the  patient  turns  on  the 
affected  side ;  and  keeps  so  till  absorption  enables  him  to 
turn  over  on  the  other  side  without  great  discomfort.  The 
existence  of  pleuritic  adhesions  will  often  cause  a  choice  of 
position  contrary  to  what  would  seem  indicated.  These 
are  most  commonly  on  the  left  side  (left  side  pleurisy  being 
much  more  frequent  than  right  side  pleurisy).  Those  adhe- 
sions limit  motion  in  respiration,  and  with  that  friction,  and 
its  resultant  suffering,  and  so  put  the  part  at  comparative 
rest.  Thus  in  a  case  of  right  side  phthisis,  the  natural 
indication  is  to  lie  on  that  side ;  but  if  the  movement  of 
the  left  side  of  the  thorax  be  hampered  by  old  pleuritic 
adhesions,  the  patient  may  find  it  easier  to  sleep  on  the 
left  side.  When  there  are  cavities  or  bronchiectases,  it  is  a 
good  practice  to  teach  the  patient  to  lie  upon  one  side  j 
after  an  hour  or  two  the  cavities  of  the  upper  lung  having 
drained  into  the  lower  lung,  the  patient  wakens;  these 
cavities  or  pits  are  emptied  by  cough,  after  which  the 
patient  lies,  and  get  some  sound  rest,  upon  the  other  side  ; 
or  the  patient  may  come  to  do  this  spontaneously.  It  is 
well  to  bear  in  mind  the  upper  lung  is  the  working  lung, 
while  the  under-lung  is  at  comparative  rest  in  the  horizontal 
position.  Keeping  this  in  view  as  a  broad  rule,  the  posi- 
tion a  patient  voluntarily  assumes,  under  the  direction  of 
his  sensations,  is  often  highly  instructive   as  regards  his 


72  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

malady  ;   that  is,  if  tlie  practitioner  will  only  first  carefully 
observe  and  then  intelligently  reflect. 

The  Voice. — This  will  often  tell  whether  the  patient  be 
generally  well  or  not.  If  loud  and  firm,  the  person  is  strong ; 
even  if  there  be  some  local  disease  of  grave  character. 
Disease  enfeebling  the  powers  will  tone  down  the  voice. 
Some  people,  however,  habitually  speak  in  subdued  accents. 
When  seeing  a  patient  in  bed  for  the  first  time,  the  tone  of 
the  voice  and  the  grip  of  the  hand  are  often  most  sugges- 
tive, and  give  information  of  the  highest  value. 

Then  the  voice  may  be  aflfected  by  a  cold ;  and  the  voice 
of  quinzy,  once  noted,  is  almost  unmistakable  ever  after. 
In  affections  involving  the  vocal  cords,  the  voice  is  a  whisper. 
Phthisis  and  syphilis  are  the  two  maladies  which  aS'ect  the 
vocal  cords ^ar  excellence.  Then 'aphonia' may  be  due  to 
overstrain  of  the  vocal  cords  in  ardent  songsters ;  or  it  may 
be  hysterical.  Girls  and  young  women  often  'lose  their 
voices'  as  a  pure  neurosis.  Sometimes  when  asked  to 
shout  they  succeed  in  speaking ;  more  frequently  the  result 
is  a  state  of  helpless  bewilderment.  Loss  of  voice  is  not 
uncommonly  feigned,  and  the  sudden  infliction  of  pain,  as  a 
pin-prick  when  the  impostor  is  oflT  his  or  her  guard,  will 
usually  elicit  an  articulate  expression  of  pain.  An  aneurysm 
may  produce  it.  Then  the  speech  is  affected  by  alcohol,  by 
aff'ections  of  the  lips,  a  polypus  in  the  nares,  enlarged  tonsils, 
and  in  the  general  paralysis  of  the  insane,  where  the 
utterance  is  thick  or  '  clipped  as  in  intoxication.' 


CHAPTER  V. 

THE  PULSE. 

The  value  of  the  pulse  in  diagnosis  has  always  been  recog- 
nised. The  Arab  and  Moorish  physicians  understood  its 
value  fully;  while  the  Chinese  carry  their  views  to  a 
ridiculous  extent,  making  the  pulse  of  the  two  sides  to 
have  different  significations ;  while  the  climax  is  reached 
by  professing  to  be  able  to  distinguish  the  sex  of  the 
foetus  in  utero  by  feeling  the  pulse  of  the  mother. 

Before  the  day  of  the  clinical  thermometer  the  pulse  was 
carefully  counted  ;  and  in  many  cases  the  watch  will  tell  a 
great  deal  in  as  many  seconds  as  the  thermometer  requires 
minutes.  Indeed,  in  all  acute  disease,  the  pulse  rate  (and 
with  that  the  character  of  the  pulse)  should  be  taken  on 
each  visit ;  if  it  Q-ives  suQ-crestive  information,  this  should  be 
corroborated  by  the  use  of  the  thermometer — will  often 
indeed  be  a  guide  to  its  use,  or  say  it  is  not  required. 
And  because  in  very  busy  club  practice  the  medical  man  has 
not  the  time  to  use  his  clinical  thermometer,  this  is  no  reason 
for  not  using  the  watch ;  rather,  to  my  mind,  it  is  a  very 
strong  argument  for  the  regular  and  systematic  use  of  the 
watch  in  regard  to  the  pulse.  The  introduction  of  the  sphyg- 
mograph  has  lessened  the  respect  once  entertained  for  feeling 
the  pulse  ;  as  if  this  last  were  to  be  laid  aside  like  an 
obsolete  instrument,  or  an  antiquated  practice.  Nothing  of 
the  kind  !  The  sphygmograph  only  writes,  so  as  to  record 
what  the  finger-tip  feels.     The  tracing  is  the  picture  of  the 


74  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

pulse  appealing  to  the  eye,  and  capable  of  being  preserved; 
while  the  sensation  of  the  pulse  is  confined  to  the  brain  of 
the  observer.  The  sphygmograph  has  not  introduced  new 
terms  in  speaking  of  the  pulse ;  it  found  a  nomenclature  ready 
to  hand.  As  to  the  ascent  of  the  pulse,  it  has  taught  us 
little;  as  to  the  descent,  it  has  helped  a  great  deal  to  clear 
our  views.  It  has  familiarised  us  with  the  *  form  of  the 
pulse,'  an  important  matter  for  learning  to  understand  it 
when  felt ;  further,  it  has  taught  us  '  the  line  of  ascent, 
corresponding  to  the  ventricular  systole  ;  the  summit  of  this 
line,  which  represents  the  condition  of  the  arterial  system 
at  the  end  of  the  systole;  and  the  line  of  descent,  which 
corresponds  to  the  flow  of  blood  from  the  arteries  to  the 
veins  during  the  diastole  of  the  heart.  It  is  with  reference 
to  the  latter,  more  especially,  that  the  sphygmograph  affords 
important  information  not  so  well  obtained  by  the  tactile 
examination  of  the  pulse'  (Austin  Flint).  The  sphygmo- 
graph should  be  used  in  the  hospital  as  a  part  of  a  medical 
education,  in  order  that  the  student  may  learn  to  under- 
stand the  pulse,  which  must  be  felt  in  practice.  About 
this  there  is  a  general  agreement  of  opinion.  '  In  ordinary 
medical  practice  the  sphygmograph  has  not  as  j^et,  and 
probably  never  will,  come  into  general  use,'  says  the  great 
clinical  authority  just  quoted.  The  practical  utility  of  the 
sphj^gmograph  for  the  great  bulk  of  practitioners  is,  that  it 
helps  them  to  learn  liow  to  feel  the  pulse. 

In  the  first  place,  always  feel  both  radial  pulses  as  an 
habitual  practice.  This  will  coi'rect  the  judgment  which 
might  be  formed  from  feeling  one  only.  In  early  days, 
when  an  apprentice  to  my  father,  it  fell  to  my  lot  one  day 
to  call  on  a  pauper  whoj  though  out  of  sorts,  was  not 
seriously  ill.  To  my  dismay,  on  attempting  to  feel  his 
pulse,  none  could  be  detected.  On  arriving  at  home,  my 
report  was  faithfully  made  ;  with  the  result  that  my  father 
went  to  see  him  at  once  at  considerable  inconvenience.  He 
found  no  pulse  either  at  the  wrist  first  taken,  but  at  once 


THE  PULSE.  75 

seized  the  other  wrist.  There  was  a  very  good  pulse.  On 
examining  for  the  cause  of  this  it  was  found  there  was 
a  severe  cut  on  the  wrist  which  had  led  to  an  irregular 
blood-flow,  and  accordingly  no  pulse  could  be  felt  where 
a  pulse  ought  to  have  been !  The  bantering  which  fol- 
lowed was  a  good  lesson.  Nevertheless,  since  aspiring  to 
the  position  of  a  hospital  physician  another  good  lesson  has 
been  administered.  A  patient  at  the  West  London  Hos- 
pital was  shown  to  many  visitors  as  a  well-marked  instance 
of  aortic  regurgitation.  One  day,  on  feeling  both  wrists,  the 
absence  of  pulsation  in  the  left  radial  told  of  an  aortic 
aneurysm  as  well,  in  all  probability.  It  was  just  as  well 
for  my  reputation  that  this  discovery  was  made  bj''  myself, 
and  not  by  one  of  the  numerous  visitors. 

It  is  well  to  feel  both  radial  arteries  habitually,  as  a  not 
uncommon  distribution  for  the  artery  is  up  the  thumb. 
The  superficialis  volse  is  usually  a  small  branch,  but  at 
other  times  it  forms  the  main  trunk  of  the  radial  ;  and  may 
be  seen  distinctly  coursing  over  the  carpal  articulation  of 
the  thumb  on  its  dorsal  aspect. 

In  feeling  the  pulse  there  are  many  matters  to  be  noted 
beyond  its  mere  rapidity.  Its  character  is  quite  as  im- 
portant as  its  rate.  Its  ratio  to  the  respiration  is  also  often 
very  suggestive.  Then  there  is  also  its  rhythm.  Its 
rapidity  tells  of  the  frequency  of  the  heart's  contractions. 
Its  character  may  depend  upon  the  condition  of  the  arterial 
walls.  The  pulse  depends  (1)  upon  the  ventricular  systole  ; 
(2)  upon  the  arterial  wall;  and  (3)  upon  the  state  of  the 
arterioles.  This  last  is  of  importance  in  febrile  conditions. 
Here  the  arterioles  are  relaxed,  and  so  permit  of  the 
blood  running  freely  out  of  the  arterial  system.  The 
accelerator  fibres  of  the  vagus  are  thrown  into  action,  and 
by  more  rapid  action  the  heart  pumps  the  blood  into  the 
unfilled  arteries.  The  opposite  condition  is  that  of  the 
arteriole  contraction  of  granular  kidneys ;  here  the  blood 
can  only  flow  out  of  the  arterial  system  slowly,  the  arterial 


76  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

tension  is  high,  the  roots  of  the  vagus  are  flooded  with 
blood,  and  its  inhibitory  fibres  are  thrown  into  action  ; 
with  the  consequence  that  the  heart's  contractions  are 
slowed.  Here  there  is  a  powerful  slowly  acting  ventricle, 
and  a  tense  pulse  ;  contrasting  with  the  rapid  slight  stroke 
(to  use  a  term  applied  to  steam  engines)  of  the  heart  in 
pyrexia,  and  the  compressible  pulse.  The  rapid  pulse 
of  the  low  arterial  tension  is  the  antithesis  of  the  slow 
pulse  of  full  arteries.  This  is  the  first  cardinal  or  funda- 
mental matter  to  be  grasped  ;  the  main  division  of  the  pulse 
to  be  kept  in  mind. 

The  Fast  Pulse. — This  may  be  due  to  nervousness  ;  and  it 
is  an  excellent  rule  to  take  the  pulse  when  the  patient  enters 
the  room,  or  you  enter  the  patient's  room ;  and  if  found  fast,  to 
wait  till  towards  the  end  of  the  interview,  and  take  it  again. 
If  then  found  much  slower,  it  is  clear  the  rapidity  found  in 
the  first  counting  of  it  was  simply  nervousness.  Then  the 
pulse  rate  is  heightened  in  fevers  and  in  inflammations  ;  and 
this  fact  will  often  tell  whether  severe  pain  is  inflammatory 
(when  the  pulse  is  quick),  or  neuralgic  (when  the  pulse-rate 
is  normal).  Or  the  pulse  may  be  rendered  rapid  by  alcohol 
recently  taken,  or  by  long-past  indulgence.  The  pulse  is 
very  rapid  in  conditions  of  dilatation  of  the  left  ventricle, 
when  a  little  blood  only  is  pumped  at  each  systole  from  the 
overfull  ventricle.  The  pulse,  too,  mounts  up  in  rate  when 
the  right  ventricle  is  being  over-distended,  and  the  patient 
is  sinking  from  thoracic  disease.  In  pulmonary  aflfections 
rapidity  of  the  pulse-rate  is  of  bad  omen.  '  In  chronic  in- 
flammations the  frequency  of  the  pulse  is  a  guide  in  judging 
of  the  degree  of  constitutional  disturbance,  or  the  tolerance 
of  them  by  the  system.  For  example,  in  pneumonic  phthisis, 
other  things  being  equal,  the  disease  may  be  said  to  be  telling 
upon  the  powers  of  life  in  proportion  as  the  pulse  is  persist- 
ently frequent.  The  symptom  has  an  important  bearing  on 
the  prognosis,  and  on  the  propriety  of  sending  patients  away 
from   home ;    the  same  is  true  of    the  chronic  aflections  * 


J 


THE  PULSE.  77 

(Austin  Flint).  This  last  remark  is  well  worth  pondering 
over.  As  to  the  rapidity  of  the  pulse  in  phthisis,  a  rapid 
pulse  is  always  to  be  disliked.  Some  old  practitioners  make 
a  forecast  of  consumption  when  the  pulse  is  persistently 
over  a  hundred ;  even  when  no  physical  signs  have  mani- 
fested themselves,  especially  in  cases  where  the  family  his- 
tory is  suggestive  of  phthisis.  In  one  case  seen  a  few  months 
ago,  a  mitral  stenosis  was  found  with  a  very  quick  pulse, 
and  an  irregular  temperature  tending  to  rise.  The  patient 
was  a  girl  previously  healthy.  She  gradually  sank  without 
any  apparently  sufficient  reason.  Dr.  Quain  suspected  some 
ulcerative  endo-carditis. 

The  Slow  Pulse. — The  pulse  is  slow  when  there  is  a  tight 
artery,  and  the  hyperti'ophied  heart  of  the  granular  kidney, 
variously  spoken  of  as  chronic  Bright's  disease,  or  *  the  gouty 
heart,'  according  to  the  peculiarities  of  each  case.  Here  there 
is  a  strong  ventricle,  a  loud  aortic  second  sound,  a  firm  pulse, 
with  the  physiological  associations  of  a  large  bulk  of  urine 
of  low  specific  gravity.  A  very  important  association  to  be 
borne  in  mind  in  practice,  as  it  will  often  furnish  the  clue 
to  the  right  interpretation  of  anomalous  or  not  very  definite 
symptoms.  Then  again  the  pulse  is  slow,  without  power,  in 
fatty  degeneration  of  the  heart ;  and  when  the  indications 
of  senile  degeneration  are  presented  with  a  slow  pulse,  the 
observer  should  be  on  the  alert ;  no  matter  whether  the  pulse 
is  a  faithful  index  of  the  cardiac  contractions,  or  whether  a 
number  of  these  contractions  are  too  feeble  to  reach  the 
radial  pulse. 

Then  abnormal  slowness  is  found  as  a  normal  condition 
in  some  persons  ;  and  a  pyrexial  state  only  gives  a  pulse  of 
normal  frequency.  A  pulse  of  forty,  or  even  less,  is  not 
rare.  This  peculiarity  may  be  found  even  as  a  family  cha- 
racteristic. Then  great  slowness  is  sometimes  the  effect  of 
digitalis.  A  slow  pulse  is  not  uncommon  in  jaundice  or 
choloemia. 

'  The  significance  of  slowness  is  the  resistance  offered  by 


78  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

arterial  tension.  By  haemorrhage,  or  the  abstraction  of  blood, 
a  slow  pulse  may  be  changed  into  one  which  is  quick,  and 
giving  the  sensation  of  increase  of  force,  the  change  being 
due  to  diminution  of  arterial  tension  '  (A.ustin  Flint). 
Perhaps  the  most  instructive  lesson  in  this  matter  is  taught 
by  the  effects  of  the  inhalation  of  nitrite  of  amyl  in  cases 
of  the  tense  slow  pulse.  In  a  few  seconds,  as  the  face 
flushes,  the  pulse  changes ;  from  the  slow,  incompressible, 
firm  pulse,  it  is  transformed  into  a  rapid,  compressible,  febrile 
pulse,  by  the  relaxation  of  the  arterioles,  caused  by  the 
action  of  the  amyl  nitrate.  In  a  few  minutes,  as  this  effect 
passes  off,  the  pulse  regains  its  primitive  character. 

A  slow  pulse,  too,  may  be  found  with  encephalic  disease, 
sometimes  as  a  consequence  of  it. 

Then  there  is  '  quickness'  or  *  slowness'  of  the  pulse, 
which  is  the  impression  given  to  the  finger  by  the  filling  of 
the  artery.  There  is  \}i\% 'pixlsiis  celer,  of  quick  filling  of  a 
slack  artery,  giving  the  high  ascent  of  a  sphygmographic 
tracing,  which  contrasts  with  the  short  sloping  ascent  of 
the  atheromatous  artery.  The  slow  pulse,  indsus  tardus, 
is  the  opposite  of  the  pulsus  celer;  its  most  typical  associa- 
tion is  that  of  aortic  obstruction  where  the  ventricle  slowly 
empties  itself  into  the  arterial  system. 

The  Slack  Pulse. — This  is  the  pulse  of  an  unfilled  artery, 
without  special  reference  to  its  cause.  The  heart  may  be 
contracting  feebly ;  the  arterioles  may  be  relaxed  so  as  to 
allow  the  blood  to  run  freely  out  of  the  arterial  system  ;  or 
the  artery  may  be  unfilled  from  deficiency  of  blood,  as  by 
haemorrhage,  or  other  drain  ;  or  from  mal-assimilation. 
This  pulse  is  easily  obliterated  by  pressure  betwixt  the 
finger-tip  and  the  osseous  structures  beneath  the  artery. 
This  pulse  goes  with  a  small  bulk  of  urine,  i.e.,  the  urine  of 
low  arterial  tension. 

The  Tight  Pulse. — Here  the  pulse  is  tight,  tense,  or  cord- 
like. It  is  the  pulse  of  high  arterial  tension.  It  goes  with 
a  large  bulk  of  urine,  and  is  usually  a  slow  pulse.     In  well- 


THE  PULSE.  79 

marked  cases  of  granular  kidney  the  artery  may  feel,  as 
Dickinson  puts  it,  'like  a  tendon.'  Such  a  pulse  is  only 
compatible  with  a  stout,  powerful  ventricle,  and  is  the 
concomitant  of  hypertrophy. 

In  pyrexial  states  the  blood  passes  into  the  opposite 
condition  of  a  fast  slack  pulse  ;  just  as  it  can  be  made  to  do 
by  the  inhalation  of  nitrate  of  amyl. 

The  Hard  Pulse. — This  is  sometimes  the  expression  used 
for  the  '  tight '  or  '  incompressible  '  pulse.  It  should  rather 
be  reserved  for  the  state  of  the  arterial  walls,  than  their 
contents.  The  atheromatous  change  is  a  hardening  of  the 
arterial  wall,  due  to  the  full  or  '  tight '  artery,  otherwise  to 
over-distension  of  the  arteries.  As  the  artery  hardens,  it 
may  grow  elongated  and  tortuous.  It  may  be  a  small  wiry 
vessel,  as  commonly  seen  in  cirrhosis  ;  or  a  thick-walled 
vessel,  as  seen  in  well-fed  gouty  persons.  This  atheromatous 
hardening  exaggerates  the  pulse,  and  gives  an  erroneous 
impression  at  times  of  the  vigour  of  the  cardiac  contrac- 
tions. Then  the  arterial  wall  may  be  the  seat  of  calcareous 
deposit,  becoming  almost  as  rigid  as  a  clay  tobacco-pipe 
stem.     Such  a  state  when  well  marked  is  unmistakable. 

The  Delayed  Pulse. — The  radial  pulse  sometimes  lingers 
behind  the  ventricular  contraction  an  undue  time.  It  has 
been  regarded  as  linked  with  aortic  insufficiency,  and  Hay- 
den  has  seen  it  in  aneurysm  of  the  aortic  arch. 

The  Visible  Pulse. — Sometimes  the  pulsations  of  the  tem- 
poral artery  and  even  the  radial  are  visible,  without  disease 
being  present.  Most  commonly  the  visible  pulse  is  found 
with  aortic  regurgitation  and  a  huge  ventricle. 

The  Bounding  Pulse. — This  is  the  full,  round,  inflammatory 
pulse.  It  indicates  vascular  excitement  with  tone.  It  is 
the  pulse  of  sthenic  inflammation  where  our  predecessors 
bled  freely,  and  sometimes  repeatedly.  Certainly  under 
venesection — I  beg  your  pardon,  my  youthful  reader,  if  you 
gave  an  involuntary  start — such  pulse  changes  its  character, 
and  markedly.    Along  with  this  the  pain  is  usually  relieved 


So  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

in  acute  inflammations,  as  pleurisy  for  instance.  There  are 
many  reflecting  country  doctors  who  take  their  lancet- 
case  about  with  them  regularly,  at  the  present  day ;  and 
make  good  use  of  the  lancet  too.  In  strong,  plethoric 
country-people,  in  acute  inflammation  with  the  bounding 
pulse,  v/hich  jerks  up  the  finger  at  each  systole,  it  is  good 
practice  to  bleed.  Such  cases  do  not,  as  a  rule,  ever  find 
their  way  into  a  large  hospital.  The  change  of  the  pulse 
under  venesection  or  vascular  depressants  is  a  matter  of 
high  diagnostic  value.  In  acute  pleurisy,  pneumonia,  acute 
Bright's  disease,  meningitis,  etc.,  such  a  pulse  is  found  in 
strong  adults.  I  have  found  it  in  a  stalwart  young  man  in 
commencing  measles. 

The  Wiry  Pulse. — Very  curiously  in  acute  inflammation 
of  the  abdominal  viscera,  and  especially  of  the  peritoneum, 
the  pulse  is  not  bounding,  but  small  and  wiry.  The  mus- 
cular coat  is  contracted,  and  the  vessel  feels  small  and  hard, 
and  in  pronounced  cases  '  like  a  pulsatile  wire.'  The  more 
rapid  such  a  pulse,  the  worse  the  case.  When  the  patient 
is  sinking  in  peritonitis,  the  pulse  mounts  in  frequency  and 
becomes  weak  and  irregular. 

In  hysteria  the  pulse  is  also  small  and  hard ;  and  in 
hysterical  peritonitis  the  pulse  is  of  little  diagnostic  im- 
portance. The  large  bulk  of  limpid  urine  which  follows  an 
hysterical  attack  tells  of  the  high  arterial  tension  of  this 
hard  small  pulse. 

The  Dicrotic  Pulse. — {Pulsus  Biferiens.)  This  is  a  pulse 
which  gives  the  impression  of  '  a  feeble  ventricular  systole 
alternating  with  one  of  much  greater  strength.' — (Flint.) 
Hayden  says,  'It  is  met  with  under  the  triple  combination 
of  abrupt  and  feeble  contraction  of  the  left  ventricle,  imper- 
fect distension  of  the  aorta,  and  diminished  capillary  re- 
sistance.'    This  pulse  gives  a  very  characteristic  tracing. 

Pulsus  Paradoxus. — In  many  persons  the  rate  of  the  pulse 
is  considerably  afiected  by  the  respiratory  act ;  being  slower 
during  inspiration,  and  faster  during  expiration.     This  fact 


THE  PULSE.  8r 

is  scarcely  enough  insisted  upon  at  the  present ;  and  the  old 
plan,  to  take  the  pulse  during  the  whole  minute,  was  a 
sound  one,  by  which  any  possible  source  of  error  of  this 
kiud  was  eliminated.  At  least  half  the  minute  is  desirable; 
a  longer  observation  being  made  when  indicated.  The 
Pulsus  Paradoxus  is  an  exaggeration  of  this  '  slowing '  and 
lowering'  of  the  pulse  with  every  inspiration,  which  is 
rendered  more  pronounced  by  a  forced  inspiration.  It  in- 
dicates a  labouring  ventricle,  usually  with  adherent  peri- 
cardium (and  pleura). 

It  is  now  time  to  consider  the  pulse  in  relation  to  disease 
of  the  heart  itself.  First  it  may  be  well  to  consider  the 
modifications  produced  by  valvular  lesions  ;  and,  then,  those 
connected  with  muscular  changes,  and  the  neurosal  affec- 
tions. 

In  Aortic  Obstruction. — When  the  aortic  orifice  is  narrowed, 
there  is  usually  compensatory  hypertrophy  of  the  left  ven- 
tricle, so  that  there  is  little  modification  of  the  pulse  produced 
thereby  ;  until  the  muscular  wall  yields  under  fatty  degene- 
ration. As  long  as  the  muscular  fibre  is  sound,  so  long  the 
rhythm  is  maintained,  and  the  pulse  has  little  about  it  of 
peculiarity.  It  may  be  said,  speaking  broadly,  the  pulse  is 
hard,  wiry,  and  incompressible.  'Hardness and  force  signify 
hypertrophy  behind  the  narrowed  orifice.' — (Walshe.)  When 
the  hypertrophy  is  yielding,  then  irregularity  follows  ;  as 
indicative  of  the  state  of  the  muscular  walls,  rather  than 
the  valve-changes. 

In  Aortic  Regurgitation. — Here,  however,  the  efi'ect  upon 
the  pulse  is  very  marked.  The  enlarged  ventricle  found 
with  the  valvular  lesion  causes  a  large  amount  of  blood  to 
be  thrown  into  the  arterial  system  on  each  systole,  by 
which  the  arteries  are  abnormally  distended.  The  recoil  is 
very  sharp,  as  the  backward  flow  of  the  blood  is  no  longer 
arrested  at  the  aortic  root.  Consequently,  this  pulse  has 
been  described  as  giving  the  impression  of  '  balls  of  blood 
shot   under   the   finger.'      It   has   otherwise   been   termed 

G 


82  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

'collapsing/  or  'jerking,'  or  'water  hammer,'  or  again, 
'  Corrigan's  '  pulse.  (From  Sir  Dominic  Corrigan's  '  Memoir 
on  Aortic  Regurgitation/)  The  peculiar  character  of  this 
pulse  is  reudered  more  distinct,  both  to  the  finger  and  the 
eyes  (by  the  sphygmograph),  if  the  hand  be  held  above  the 
level  of  the  head.     Corrigan  pointed  out  how  this  pulse  is 

*  visible '  in  marked  cases,  Sibson  has  shown  that  the 
collapse  might  be  heard  by  placing  the  patient's  wrist  to 
the  ear. 

When  aortic  regurgitation  is  complicated  by  stenosis, 
then  this  characteristic  pulse  is  modified.  When  some 
stenosis  is  also  present,  this  pulse  is  less  pronounced.  The 
same  is  the  case  where  mitral  regurgitation  has  followed  in 
its  turn,  and  Prof.  Geo.  Johnson,  F.R.S.,  has  demonstrated 
how  this  addition  may  be  detected  very  readily  by  holding 
the  hand  above  the  patient's  head.  The  mitral  leak  is  then 
very  perceptible  in  lessened  distension  of  the  artery  on 
systole,  and  some  irregularity  in  volume.  When  mitral 
stenosis  is  present,  the  characters  of  aortic  regurgitation 
are  toned  down  somewhat.  When  the  muscular  walls  be- 
come the  seat  of  fatty  degeneration,  then  long  halts  may 
show  themselves,  and  the  more  stenosis  is  mixed  with  the 
insufficiency,  the  more  this  is  marked. 

The  'steel-hammer'  pulse  is  seen,  or  rather  felt,  in  or 
near  joints  the  subject  of  acute  rheumatism  in  cases  of 
aortic  regurgitation.  '  The  pulse  is  abrupt  and  energetic, 
as  the  rebound  of  a  smith's  hammer  from  the  anvil.' — 
(Hay  den.)  The  pulsations  of  aortic  regurgitation  may  often 
be  felt  as  far  as  the  anterior  tibial,  or  seen  in  the  retinal 
artery.  In  some  cases  the  pulsation  will  be  seen  in  the 
brachial  artery,  from  close  to  the  axilla  down  to  the  wrist, 
coming  swiftly  like  a  flash.     Here  the  pulse  is  aptly  termed 

*  locomotive,'  and  its  instantaneous  character  is  very  dis- 
tinct in  the  sudden  distension,  and  the  equally  abrupt  'fall 
back.' 

In  Mitral  Stenosis. — In  consequence  of  the  obstruction  of 


THE  PULSE.  83 

the  blood-flow  at  the  mitral  orifice,  the  arterial  current  is 
feeble,  and  the  pulse  small.  About  this  all  authorities  are 
agreed.  It  may,  too,  be  rapid  at  times  and  in  some  cases. 
As  to  how  far  it  is  irregular  opinions  vary,  George  Balfour 
insists  that  it  is  irregular,  and  Dr.  James  Andrew  agrees 
with  him.  On  the  other  hand,  in  my  experience  there  is 
no  irregularity  in  mitral  stenosis,  and  in  this  view  Dr. 
Broadbent  shares,  always  admitting  irregularity  in  the 
final  stages  of  mitral  lesions.  Dr.  Walshe  goes  further, 
saying,  '  And  it  must  not  be  forgotten  that  mitral  stenosis 
tends  to  equalize  the  irregular  pulse  of  mitral  insufficiency.* 
Flint  says  of  the  mitral  lesions :  '  The  pulse  is  small  in 
proportion  to  the  amount  of  obstruction  and  the  quantity 
of  blood  which  regurgitates.  After  dilatation  of  the  heart 
has  taken  place,  the  pulse  is  often  weak,  irregular,  un- 
equal.' Hayden  wrote  :  '  The  pulse  of  mitral  obstruction 
is  usually  quite  regular,  and  not  above  ninety  in  the 
minute,  but  small ;'  irregularity  showing  itself  in  the  final 
stages,  and  with  this  view  Dr.  Sansom  agrees.  Thus  the 
testimony  is  unanimous  as  to  irregularity  in  the  later 
stages;  but  views  diametrically  opposite  obtain  as  to 
irregularity  in  the  earlier  stages. 

In  Mitral  Kegurgitation. — As  to  irregularity  with  this 
lesion  no  difference  of  opinion  exists.  The  pulse  is  ir- 
regular alike  in  volume  and  in  time :  in  volume,  according 
to  the  amount  of  regurgitation  through  the  mitral  orifice 
at  each  systole ;  irregular  in  time  (as  well  as  volume) 
according  to  the  vigour  of  each  ventricular  contraction. 
The  irregularity  in  volume  belongs  then  rather  to  the 
leak;  irregularity  in  time,  to  the  muscular  failure.  The 
irregularity  in  volume  is  often  sufficient  to  tell  of  mitral 
insufficiency  before  the  chest  is  examined.  As  compared 
to  stenosis,  insufficiency  produces  more  pronounced  effects 
upon  the  pulse  ;  whether  mitral  or  aortic. 

In  mitral  lesions  in  '  the  gouty  heart '  there  are  some 
points  to  be  Doticed.     Here  the  valvulitis  comes  on  after 

6—2 


84  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

a  certain  amount  of  hypertrophy  has  been  long  existent. 
Consequently  there  is  the  firm  strong  pulse  of  the  gouty 
heart  as  the  main  characteristic ;  and  upon  this  comes  the 
efi'ect  of  the  lesion.  The  irregularity  in  mitral  insufficiency 
usually  speaks  for  itself;  for  irregularity  is  not  part  of 
well-fed  hypertrophy.  But  in  stenosis  the  case  is  different. 
The  effect  here  is  to  diminish  the  vigour  of  the  pulse ; 
indeed,  to  cut  away  the  characters  of  the  pulse  of  the  gouty 
heart,  and  bring  the  pulse  nearer  to  that  of  the  normal 
heart.  Consequently  nothing  but  physical  examination 
will  tell  of  this  lesion ;  and  it  should  never  be  forgotten 
when  an  elderly  person,  especially  a  male,  complains  of  not 
being  so  equal  to  effort  as  of  yore.  Indeed,  when  the 
appearance  is  that  of  gout,  and  the  artery  is  hard,  it  is  well, 
to  listen  for  the  ominous  but  very  localised  murmur — here 
most  significant.  Then  come  the  relations  of  the  pulse  to 
the  muscular  walls  of  the  heart. 

In  Hypertrophy. — Wherever  there  is  hypertrophy  there 
is  a  certain  amount  of  vigour  and  tone  in  the  pulse.  It  is 
full,  firm,  and  incompressible.  When  the  arterial  wall  is 
atheromatous,  these  characters  are  intensified.  When  there 
is  aortic  narrowing,  then  they  are  less  pronounced.  There 
are  indeed  the  changes  produced  by  hypertrophy,  before  the 
valve-lesion,  to  be  calculated  in  '  the  gouty  heart,'  whether 
aortic  or  mitral ;  as  well  as  the  subsequent  hypertrophy,  as 
in  primary  valvular  lesions.  And  for  this  calculation 
individual  thought,  involving  the  capacity  to  think  ac- 
curately, is  essential.  No  amount  of  description  will  do  the 
thinking  for  the  reader;  it  must  be  done  by  himself  and 
for  himself. 

In  the  Gouty  Heart. — Here  there  is  not  only  a  firm  pulse 
on  systole,  but  the  artery  is  full  during  diastole,  in  conse- 
quence of  the  contracted  arterioles  obstructing  the  blood - 
flow  out  of  the  arteries.  It  is  essentially  the  'full  artery,' 
whether  there  be  much  atheroma  in  the  arteries  or  not. 
Whatever    the    modification    produced    by  accompanying 


THE  PULSE.  85 

valvulitis,  usually  subsequent,  though  not  always,  this  is 
the  essential  feature  of  the  pulse  in  the  gouty  heart. 

In  Dilatation. — In  dilatation  the  pulse  lacks  tone,  as  dila- 
tation is  caused  by  asthenia  of  the  muscular  fibre.  Conse- 
quently, as  women  are  more  liable  to  conditions  of  asthenia 
from  imperfect  assimilation  than  men,  dilatation  of  the 
heart-walls  is  more  constantly  found  with  women  than  with 
men ;  though  of  course  common  enough  with  the  latter 
Not  only  is  there  a  lack  of  vigour  generally,  but  the  ventri- 
cular contractions  are  unequal,  some  being  more  complete 
than  others.  The  result  is  the  pulse  of  dilatation  is  irregular 
in  volume.  In  simple  dilatation  the  pulse  is  small,  com- 
pressible, and  irregular,  as  a  small  quantity  of  blood  is 
pumped  out  at  each  stroke.  When  a  mitral  leak  is  the 
result  of  the  dilatation,  than  the  feebleness  and  irregularity 
in  volume  are  accentuated ;  the  pulse  being  a  mere  flutter, 
or  '  a  wobbling  threadJ 

Hypertrophy  and  dilatation  are  very  commonly  blended. 
Consequently  the  pulse  possesses  something  of  a  mixed 
character.  The  vigorous  stroke  of  hypertrophy  is  felt  occa- 
sionally amidst  the  feeble  pulsations  of  dilatation  :  when 
the  hypertrophy  is  the  smaller  factor.  When  the  dilatation 
is  the  lesser  and  hypertrophy  the  leading  feature,  then  the 
feeble  impulse  is  felt  amidst  a  majority  of  vigorous  strokes. 
Consequently  when  a  dilated  heart  is  gathering  itself 
together  under  digitalis,  the  pulse  tells  of  the  improvement 
in  the  ventricular  contractions,  by  a  larger  proportion  of 
vigorous  impulses.  When,  on  the  other  hand,  an  hyper- 
trophied  heart  is  yielding  under  tissue  degeneration,  then 
the  falter  becomes  more  frequent,  and  the  proportion  of 
vigorous  strokes  less  ;  and  this  is  intensified  by  the  effect  of 
a  slight  effort.  The  halt  in  the  rhythm  followed  by  a 
stronger  impulse  tells  of  this  condition ;  though  there  is  a 
point,  to  be  discussed  further  on,  which  separates  this  from 
the  mere  halt  of  a  neurosal  trick   (p.  88).     In  dilatation 


86  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

one  cr  more  feeble  strokes  precede   the   halt ;    while  the 
neurosal  halt  is  usually  preceded  by  perfect  rhythm. 

There  is  a  difference  in  the  action  of  the  heart  according 
as  there  is  yielding,  or  not,  of  the  sound  muscular  fibres  in 
the  decaying  heart.  Where  there  is  yielding  of  the  sound 
fibres  in  a  heart  once  hypertrophied,  the  pulse  is  that  of 
hypertrophy-with-dilatation,  viz.,  irregular  in  force,  accord- 
ing as  the  sound  fibre  contracts  vigorously  or  feebly. 

In  the  Fatty  Heart. — Hayden  says  :  '  There  is  in  all  cases 
evidence  of  partial  failure  of  the  circulation  under  the  form 
of  weak  irregular,  intermittent,  or  very  slow  action  of  the 
heart  and  radial  pulse,'  recognising  the  distinction  just 
made  above.  Da  Costa  speaks  of  '  a  pulse  permanently 
slow,  or  permanently  frequent  and  irregular,'  especially  if 
there  be  evidences  of  senile  changes  in  the  arteries  and 
elsewhere.  Flint  writes  of  its  semeia — '  One  of  these  is  in- 
frequency  of  the  pulse.  Cases  have  been  reported  in  which 
the  pulsations  were  reduced  to  30,  20,  15,  and  even  9  or  10 
per  minute.  It  is  possible,  if  not  presumable,  that  in  some 
of  these  cases  the  pulse  did  not  accurately  represent  the 
number  of  ventricular  contractions  ;  certain  of  these  being 
too  weak  to  cause  an  appreciable  pulsation  of  the  radial 
artery.  However  that  may  be,  notable  infrequency  of  the 
pulse  occurs  but  rarely  in  connection  with  fatty  degenera- 
tion, and  it  occurs  as  a  sj^mptom  of  a  purely  functional 
disordei\  Its  occurrence  with  fatty  heart  probably  denotes 
only  an  associated  neuro-pathic  affection.'  The  fatty  heart, 
as  compared  with  the  dilated  heart,  has  a  pulse  slow,  quiet, 
and  feeble,  with  syncope  on  effort — an  ominous  quietude 
indeed ;  where  dilatation  is  induced  b}'-  structural  decay, 
there  is  an  irregular,  tumbling,  tossing  heart  with  palpita- 
tion on  effort.  Often  there  is  a  blend  of  these  two  oppo- 
sites,  and  then  there  is  a  pulse  lacking  in  tone  (in  divers 
ways),  with  evidence  of  tissue-decay  elsewhere. 

And  now  something  may  be  said  of  irregularity  and 
intermittency,  which  may  be  linked  with  muscular  failure, 


THE  PULSE.  87 

or  be  pure  neuroses — a  discrimination  of  very  considerable 
moment.  Much  avoidable  misery  has  been  entailed  by 
confounding  one  with  the  other ;  assuming  structural  decay 
when  there  was  only  a  neurosis  present. 

Irregularity. — As  said  before,  irregularity  is  the  associate 
of  the  dilated  heart.  When  the  muscular  fibrillas  are 
stretched,  the  rhythm  of  the  heart  is  disturbed.  It  has  a 
tossing,  tumbling  action,  which  is  increased  when  any 
effort  is  necessitated.  Its  essential  feature  is — some  regular 
strokes,  then  two  or  three  short  imperfect  strokes,  a  brief 
halt,  and  then  a  full  contraction.  This  is  the  pulse  of  failing 
hypertrophy.  It  is  well  to  familiarize  the  finger  with  this 
pulse,  comparing  it  with  the  cardiac  sounds.  Or  the  irre- 
gularity may  be  imitated  by  tapping  a  table  with  the  long 
finger  with  advantage.  The  short  strokes  before  the  pause 
distinguish  it  from  the  simple  halt,  common  enough,  which 
is  a  mere  nervous  trick.  Yet  this  last  is  being  constantly 
mistaken  for  the  more  ominous  irregularity  of  a  faltering 
heart- wall. 

Then  the  pulse  is  irregular  in  exophthalmic  goitre,  corres- 
ponding to  the  tumultuous  action  of  the  heart;  and  the 
same  is  found  along  with  chorea,  especially  in  girls. 

Then  there  is  irregularity  in  the  pulse  of  '  the  irritable 
heart,'  of  which  the  marked  feature  is  the  increase  of  beats 
produced  by  standing  up  ;  which  is  greatly  in  excess  of  the 
normal  increase,  some  five  or  ten  beats,  according  to  the 
individual.  But  in  the  irritable  heart  the  increase  is  from 
twenty  to  thirty  beats  per  minute  on  rising. 

Then  there  is  the  irregular  pulse  of  persons  with  con- 
genitally  small  hearts,  where  the  stroke  is  frequently  lack- 
ing in  power. 

Then  disturbance  of  rhythm  may  be  due  to  some  brain 
disease.  *  In  acute  and  chronic  diseases  of  the  base  of  the 
brain,  the  rhythm  of  the  heart  is  often  greatly  changed, 
and  this  is  probably  due  to  irritation  or  paralysis  of  the 
cardio-inhibitory  centre  in  the  medulla.' — (James  Ross.) 


1 


88  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

Intermittency. — This  may  occur  ■with  irregularity,  or  be  a 
distinct  affection.     There  are  three  forms. 

1.  The  pure  halt. 

2.  The  halt  with  irregularity. 

3.  The  halt  with  defective  beats. 

1.  The  pure  halt.  This  is  a  pause  occurring  amidst 
regular  equal  strokes.  It  may  be  so  frequent  as  to  occur 
every  eight  or  ten  beats,  or  only  be  found  once  in  seventy, 
or  in  one  hundred  strokes.  It  is  a  nervous  trick  without 
significance.  It  is  quite  common  in  men  advanced  in  years, 
yet  without  evidences  of  any  decay  or  degeneration  in  the 
heart.  It  may  occur  in  younger  men.  Dr.  B.  W.  Richard- 
son, F.R.S.,  was  the  first  to  clear  up  cardiac  intermittency 


of  nervous  association.  It  may  occur  after  emotion,  as 
shipwreck,  or  the  shock  of  hearing  of  the  death  of  an 
intimate  friend  ;  or  like  causes  of  disturbance.  In  a  case 
seen  lately — a  Canadian — the  halt  dated  from  severe  exer- 
tion and  excitement  in  a  fire  at  his  store.  Sometimes  it 
gradually  passes  away,  more  or  less  completely  ;  or  it  may 
remain  permanently. 

2.  The  halt  with  irregularity.     Here  the  especial  feature 
of  the  case  is  the  short  strokes  occurring  rapidly  immediately 


THE  PULSE.  89 

in  front  of  the  halt ;  the  halt  being  followed  by  a  com- 
paratively powerful  beat.  The  preceding  pulse-tracings 
show  these  two  forms  of  intermittency  very  clearly. 

In  the  first,  the  beats  are  all  equal  till  the  halt  arrives. 
In  the  other,  the  small  beats  preceding  the  halt  are  dis- 
tinctly to  be  seen. 

3.  The  halt  with  defective  beats.  Here  there  is  quite  a 
different  halt  from  the  two  preceding  varieties.  The  ventricle 
contracts  sometimes  fairly  well,  at  other  times  very  im- 
perfectly, so  imperfectly  that  some  pulse-waves  do  not 
reach  the  wrist  at  all  ;  while  others  are  nearly  lost  on  the 
way.  The  following  tracing  is  too  regular  in  its  defective 
beat  to  be  typical. 


The  full  and  the  incomplete  contraction  of  the  ventricle 
is  excellently  shown,  but  they  rarely  occur  so  rhythmically, 
or  so  frequently,  as  in  this  tracing.  This  halt  is  common 
with  fatty  degeneration,  and  the  disturbance  is  increased 
by  any  effort.  In  cold  weather,  old  people  with  failing 
hearts  will  often  manifest  this  form  of  intermittency,  or  it 
may  follow  a  severe  fever.  In  one  case  known  to  me,  the 
heart's  action,  after  a  severe  attack  of  typhoid,  was  terribly 
intermittent  and  defective.  Long  swoons  were  of  frequent 
occurrence.  Gradually  and  slowly  it  wore  off  to  a  great 
extent.  Then  the  heart  falters  markedly  when  death  is 
approaching,  especially  in  thoracic  affections.  Here  it  is 
the  right  side  which  is  failing.  The  following  tracing  tells 
of  the  intermittency  of  approaching  dissolution.  The  heart 
is  staggering  and  faltering,  just  as  a  wounded  man  staggers 
and  falters  before  he  finally  drops. 

Not  only  is  it  very  desirable  that  the  medical  man  be 
able  to  discriminate  these  different  varieties  of  intermittency, 


90  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

so  as  to  differentiate  one  from  another ;  but  it  is  well  to 
understand  the  import  of  the  intermittency  prognostically 
from  day  to  day,  as,  for  instance,  the  lessening  thereof  in 
recovery  from  acute  disease ;  or  the  increase  when  the 
powers  are  failing. 

There  is,  too,  another  point  to  be  attended  to,  viz. :  the 
relations  of  the  radial  pulse  to  failure  of  the  right  heart. 
The  intermittency,  with  or  without  irregularity,  is  due  to 
the  left  ventricle  keeping  time  with  the  right.   It  is  well  to 


compare  the  pulse  with  the  heart's  beats,  listening  to  the 
latter  while  the  finger  is  on  the  radial  pulse.  It  will  be 
found  that  the  radial  pulse  is  not  quite  so  faithful  an 
index  of  the  ventricular  contraction,  when  the  right  side  of 
the  heart  is  involved,  as  it  is  when  it  is  the  left  ventricle 
which  is  affected. 

Disturbed  Rhythm  in  Digestion. — Then  there  are  disturb- 
ances of  the  heart's  rhythm,  set  up  by  the  digestive  act. 
There  may  be  flatulence,  and  the  pressure  of  the  elastic 
gas  upon  the  thin  tendinous  portion  of  the  diaphragm  em- 
barrasses the  action  of  the  heart.  At  other  times  there  is 
indigestion  in  fairly  healthy  persons,  from  unsuitable  food  ; 
in  others  an  ordinary  meal  will  produce  irregularity  in  the 
heart's  action.  Sometimes,  instead  of  tumultuous  action 
giving  an  irregular  pulse,  there  is  a  simple  halt.  The 
patient  may  not  be  conscious  of  this  in  some  cases ;  but  in 
other  cases  the  individual  is  acutely  conscious  of  it,  and 
may  be  alarmed  thereat.  It  is  held  that  the  disturbance 
is  brought  about  by  an  action  through  the  vagus. 

Arrested  Action, — All  are  now  familiar  with  the  fact  that 


THE  rULSE.  91 

there  are  inhibitory  fibres  in.  '  that  rope  of  mingled  strands ' 
the  vagus  nerve ;  when  the  roots  of  the  vagus  are  flooded 
with  blood,  these  fibres  are  thrown  into  action,  and  the 
heart  is  slowed.  Sometimes  irritation  in  some  part  of  the 
body  will  act  through  these  inhibitory  fibres,  and  then  the 
pulse  is  slow  and  feeble,  like  the  pulse  of  fatty  degeneration. 
The  subjective  sensations  are  those  of  incapacity  to  move, 
or  even  swooning.  Indeed,  swooning  or  fainting  is  usually 
arrest  of  the  heart's  action  through  the  agency  of  these 
inhibitory  fibres.  Cases  of  arrested  action  are  not  sufficiently 
common  to  make  all  familiar  with  the  affection.  Yet  it  may 
occur  in  a  very  stalwart  young  person. 

Accelerated  Action. — Beyond  the  inhibitory  fibres  the 
-vagus  contains  accelerator  fibres.  One  emotion  will  act 
through  the  inhibitory  fibres,  producing  a  cold  sweat  or 
faint ;  another  will  act  through  the  accelerator  fibres,  and 
cause  the  heart  to  beat  rapidly  and  violently.  Especially  is 
this  the  case  where  there  is  also  a  blush,  i.e.,  dilatation  of 
the  terminal  arterioles,  with  a  low  blood  pressure  in  the 
arteries.  This  eff'eet  of  a  sudden  fall  in  the  blood  pressure 
upon  the  heart's  contractions,  is  readily  seen  after  the  in- 
halation of  amyl.  As  well  as  emotional  acceleration  of  the 
heart,  there  are  cases  where  this  rapidity  of  action  will 
come  on  in  paroxysms  from  other  causes.  Just  as  arrested 
action  may  occur  at  intervals  in  some  cases ;  so  in  others 
the  heart  will  suddenly  beat  with  great  rapidity,  say  from 
160  to  200  per  minute  for  a  while,  and  then  settle  down  to 
the  ordinary  rate.  These  conditions  cause  much  alarm 
usually,  because  their  interpretation  is  not  understood  or 
comprehended  rightly. 

Unequal  Pulse. — When  the  pulse  is  unequal,  the  beat  at 
one  wrist  being  less  forcible  than  that  at  the  other,  then 
there  is  usually  an  aneurysm  involving  the  root  of  the  sub- 
clavian artery.  But  any  other  pressure  may  produce  this 
result ;  or  the  artery  may  have  been  more  or  less  completely 
obliterated  by  injury,  or  by  the  growth  of  an  atheromatous 


92  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

patch  at  or  near  its  origin.     At  other  times  it  is  part  of  a 
neurosis  merely,  and  of  no  great  significance. 

Venous  Pulsation. — Sometimes  there  is  a  venous  pulse» 
when  the  capillaries  admit  of  the  arterial  pulsation  being 
continued  into  the  veins.  Usually,  however,  venous  pulsa- 
tion is  connected  with  the  condition  of  the  right  side 
of  the  heart.  It  does  not  necessarily  follow  that  there  shall 
be  actual  tricuspid  regurgitation  ;  though,  of  course,  when 
that  is  the  case  the  pulsation  in  the  great  venae  of  the  neck 
is  very  conspicuous.  But  at  times  the  contraction  of  the 
right  ventricle  sends  an  impulse  into  the  venje  cavse  in 
closing  the  tricuspid  valves.  But  even  if  there  be  not  actual 
insufficiency  in  the  valve  curtains,  venous  pulsation  tells  of 
right  side  dilatation.  It  may  be  that  a  pulse-wave  may 
at  times  be  due  to  the  contraction  of  the  muscular  fibres  in 
the  coats  of  the  vense  cavse  near  the  auricle. 

Venous  pulsation  has  only  a  limited  range  of  relation,  as 
compared  to  the  arterial  pulse,  which  has  far-reaching  asso- 
ciations. 

Though  the  sphygraograph  can  never,  in  its  present  form, 
come  into  general  use,  the  visible  tracing  is  the  permanent 
record  of  what  the  finger  feels  ;  or  at  least  is  the  only  known 
means  by  which  the  impression  received  by  the  finger  can 
be  made  manifest  to  others.  Consequently  pulse-tracings 
have  a  high  educational  value,  and  should  be  studied  as  a 
means  of  educating  the  finger  to  feel  correctly.  This  know- 
ledge of  the  pulse  was  an  important  matter  with  the  great 
men  of  the  past,  who  gained  that  knowledge  painfully  and 
bit  by  bit.  And  acquaintance  with  the  pulse  must  come 
back  again  ;  especially  in  the  study  of  affections  of  the  heart 
and  the  blood-vessels.  The  murmur  is  now  the  test  of 
valvular  diseases ;  but  there  are  cases  where  no  doubt  can 
exist  that  there  is  a  valvular  lesion,  and,  further,  what  its 
nature  is  where  no  murmur  is  to  be  heard ;  while  in  other 
cases  there  exists  a  murmur  often  pronounced,  without  any 
reason  to  suspect  organic  disease.     In  the  full  belief,  then, 


THE  PULSE.  93 

that  valvular  lesions  can  be  profitably  studied  from  their 
physiological  side,  as  well  as  from  the  side  of  physical  exa- 
mination, a  series  of  sphygmographic  tracings  will  now  be 
given,  to  my  mind  of  high  educational  value.  They  are 
selected  by  Dr.  F.  A.  Mahomed,  from  his  rich  collection  of 
tracings,  with  special  reference  to  the  title  of  this  work  :  and 
the  selection  has  been  very  judiciously  made.  The  study 
of  the  series,  contrasting  one  tracing  with  another,  will  do 
much  to  show  the  value  of  'the  physiological  factor  '  in  the 
study  of  disease  in  its  clinical  aspects.  By  the  careful 
study  of  this  series  of  tracings  the  practitioner  will  readily 
learn  to  grasp  the  information  furnished  by  the  finger  ;  for 
the  finger  is  always  at  hand,  and  can  be  applied  in  a  few 
seconds  to  gain  the  desired  information — if  the  requisite 
knowledge  exist  in  the  cerebral  centres  with  which  the 
finger  communicates.  It  is,  then,  in  the  expectation  that  the 
reader  will  so  learn  to  educate  his  finger,  rather  than  in  any 
hope  that  the  use  of  the  sphygmograph  can  become  general, 
that  the  foUowinof  tracings  are  given. 

In  illustration  of  what  is  meant,  it  may  somewhat  sur- 
prise the  youthful  reader  that  in  the  Lancet  for  December 
14th,  1833,  the  late  Dr.  Archibald  Billing]wrote  a  letter  on 
*  Early  Detection  of  Aneurysm  in  the  Chest.'  He  found 
a  resilient  pulse  in  unmistakable  cases,  and  from  its  study 
made  his  diagnosis  in  other  cases.  He  says :  '  When  the 
resilience  is  slight,  it  requires  some 'practice  to  feel  it,  and 
the  fingers  must  be  kept  with  a  light  elastic  pressure  on 
the  artery  at  the  wrist.'  In  the  Lancet  for  March  8th, 
]  834,  appears  the  following  letter  from  him  : 

'Sir, — One  of  the  patients  alluded  to  in  my  letter  of 
the  3rd  of  November  last  has  since  died,  and  upon  'post- 
mortem  examination  an  aneurysm  of  the  aorta  was  found, 
close  to  the  heart,  not  larger  than  a  connnon  hen's  egg. 
There  was  also  hypertrophy  and  dilatation  of  the  left 
ventricle.  I  believe  this  to  be  the  smallest  aneurysm  of 
the  aorta  of  which  the  existence  has  been  detected  during 


94 


PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


life  ;  at  the  same  time  I  must  observe  that,  in  my  opinion 
the  state  of  the  left  ventricle  assisted  the  diagnosis.' 

This  shows  what  the  education  of  the  finger  means  far 
more  forcibly,  and  eloquently,  than  any  words  of  mine 
could  do. 

Further,  the  tracing  of  the  pulse  of  high  arterial  tension 
is  becoming  increasingly  valuable  in  the  detection  of  granular 
kidney,  where  albuminuria  is  only  fitfully  present.  Con- 
versely the  albuminuria  of  peptones  does  not  necessarily 
involve  any  increased  arterial  tension.  Also  in  less  perma- 
nent conditions  of  blood  surcharged  with  nitrogenised  waste, 
the  state  of  the  artery  is  of  inestimable  value  diagnostically, 
and  therapeutically.  Dr.  Mahomed  has  also  added  several 
tracings  showing  the  effects  of  treatment,  of  high  significance 
in  illustrating  the  action  of  remedial  agents  upon  the 
circulation. 

Varieties  of  the  Normal  Pulse. 


I 


Showing  varying  degrees  of  arterial  tone,  characteristic  of 
the  individual. 


\ 


A  healthy  man.     Pressure,  .3  ozs. 


A  healthy  woman.    Pressure,  2  ozs. 


THE  PULSE. 


95 


A  hard-worked  medical  student,  with  diminished  tone. 
Pressure,  3  ozs. 

The  Pulse  of  High  Arterial  Pressure. 

Pressure,  6  ozs.  |  Pressure,  4  ozs. 


In  an  otherwise  healthy  woman,  aged  27.   (Functional  stage  of  Chronic 
Bright's  disease.) 


In  a  man,  aged  68,  without  albuminuria.     Pressure,  2s^  ozs. 


In  acute  albuminuria  after  scarlet  fever.     Pressure,  5  ozs. 


A  man  aged  30.     Chronic  Bright's  disease,  with  dropsy  for  2  years, 
heart  hypertrophied.     Pressure,  6  ozs. 


96  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


An  aged  luau.    (jiironic  J4rigiii\s  ui^ease,  witn  clilaLed  heart.    Pres- 
sure, 7  ozs. 

The  pulse  tracing  of  atheromatous  vessels  is  practically 
that  of  high  pressure,  or  of  an  hypertrophied  heart ;  the 
collapse  of  the  tidal  wave  is,  perhaps,  unusually  sudden. 


A  man  aged  45,  with  gangrene  of  the  foot  and  extreme  atheroma  of 
his  vessels.     Pressure,  5  ozs. 

The  pulse  in  aneurysm  often  gives  no  indication,  or  only 
a  slight  one  ;  sometimes  the  effect  is  very  pronounced. 


From  a  case  of  Aneurysm  of  the  Innominate  and  Transverse  Arches. 
Pressure,  1  oz.     Plight  radial. 

Tracings  FROii  One  Patjent,  showing  Variations  occur- 
ring DURING  a  Severe  Attack  of  Typhoid  Fever. 


The  worst  form— an  undulating  hyperdicrotic  pulse.     Pressure,  4  ozs. 


THE  PULSE. 


97 


Heart  gaining  power,  after  free  stimulation.    Hyperdicrotic,  but  witli 
good  systole.    Pressure,  3  ozs. 


Recovering.    Dicrotic,  but  no  longer  hyperdicrotic.    Pressure,  2  ozs. 


Convalescent,  but  heart  laboured  and  enfeebled.     Pressure,  7  ozs. 


Digitalis  given.    Heart  strengthened.    Systole  of  good  power. 
Pressure,  2  ozs. 

Varieties  of  Pulse  in  severe  Fever. 


The  mono-erotic  pulse,  often  seen  in  severe  pericarditis,  which  was 
present  in  this  case.    Pressure,  6  ozs. 

7 


PHYSIOLOGICAL  FACTOR  LN  DIAGNOSIS. 


The  liyperdicrotic  pulse  ot  severe  pyrexia,  without  iailing  heart. 
Pressure,  2  ozs. 

Forms  of  Pulse  associated  with  severe  Aortic 

Stenosis. 
In  some  cases  the  pulse  is  not  appreciably  affected.     Both 
of  these  cases  show  slow  and  laboured  systole. 


A  man  ijet.  37,  with  phthisis  and  severe  aortic  stenosis.    Pressure, 

l\  ozs. 


A  more  rare  form.    Pressure,  3  ozs. 
Mitral  Stenosis. 
The  pulse  is  often  perfectly  normal  in  appearance,  like  that 
of  mitral  regurgitation,  from  which  it  cannot  be  distinguished. 


Simultaneous  heart  and  pulse  trace,  to  show  the  '  pulsus  biferiens, 
i.e.,  the  ineflfectual  contraction  of  the  heart  which  does  not  open 
the  Aortic  valves.     Pressure,  3  ozs. 


THE  PULSE. 


99 


Mitral  stenosis  producing  byperdicrotism  and  rapid  action  of  heart. 
Pressure,  1  oz. 


From  the  same  case  as  the  last,  after  taking  Digitalis  for  20  days. 
Pressure,  1^  ozs. 


Forms  of  Pulse  seen  in  Aortic  Regurgitation. 


Woman,  set.  62.     Aorta  good.     Free  regurgitation.     Simulates  high 
arterial  pressure.    Pressure,  1  oz. 


A  typical '  splash'  or  '  water-hammer '  pulse.     Pressure,  2  ozs. 

7—2 


loo         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


Aortic  regurgitation  under  the  influence  of  Digitalis.     Violent 

systole. 

Mitral  Regurgitation. 


A  boy,  aged  K),  with  much  dilatation  and  mitral  regurgitation,  show- 
ing the  short,  collapsing  systole.     Pressure,  1  oz. 

Effect  of  Digitalis. 


The  characteristic  rapid,  irregular,  and  failing  heart  of  mitral  regur- 
gitation with  dilatation.     Pressure,  1  oz. 


From  the  same  case  as  the  last,  after  taking  Digitalis  for  9  days. 
Pressure,  1  oz. 


CHAPTER  VI. 

THE  ALIMENTARY   CANAL. 

This  gives  a  variety  of  indications,  from  the  uncomfortable 
pharyngeal  hawking  of  dyspepsia  to  the  pruritus  ani 
of  seatworms  or  the  worry  of  an  external  pile.  The  first 
act  of  importance  is  the  modification  of  the  act  of  swallow- 
ing, or  dysphagia. 

Dysphagia. — This  may  be  due  to  an  abscess  behind  the 
pharynx,  to  oedema  of  the  epiglottis,  or  enlarged  cervical 
glands.  It  is  more  commonly  associated  with  aneurysm  of 
the  great  vessels  of  the  root  of  the  neck,  and  with  stricture 
of  the  oesophagus  ;  or  it  may  be  a  foreign  body  impacted  in 
the  gullet.  In  stricture  in  a  young  woman  it  will  probably  be 
hj'^sterical ;  in  an  elderly  man  it  is  usually  cancerous,  though 
it  may  be  a  fibrous  stricture  brought  on  by  swallowing  soap- 
lees,  for  instance,  or  it  may  be  neurosal.  So  far  as  is  known 
to  me,  the  characters  of  the  act  of  swallowing  in  dysphagia 
liave  not  been  carefully  studied.  Usually  there  is  only  the 
capacity  to  get  down  small  quantities  at  once  in  stricture 
or  pressure.  Some  time  ago,  I  was  called  far  away  to  a  case 
where  there  was  dysphagia,  with  little  else,  only  a  patch  of 
dulness  at  the  back.  Consequently,  it  became  essential  to 
study  the  act  of  swallowing  carefully.  A  small  quantity 
was  certainly  returned,  while  half  a  tumberful  of  fluid  could 
be  gulped  down  successfully.  The  opinion  given  was,  that 
there  was  partial  paralysis  of  the  gullet  (corresponding  to 
the  area  of  dulness  at  the  back),  and  that  it  was  not  stricture 


102         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

nor  pressure  ;  and  the  opinion  was  verified  by  the  gradual 
disappearance  of  the  dysphagia.  Further  observation  of 
the  act  of  swallowing  would  probably  repay  the  trouble 
taken. 

Vomiting. — This  is  due,  not  only  to  the  contraction  of 
the  stomach  itself,  but  of  the  diaphragm  and  abdominal 
muscles.  It  is  said,  in  one  case  at  least,  of  poisoning  by  a 
corrosive  acid,  a  large  piece  of  the  stomach  was  vomited 
before  the  patient  died.  Vomiting  may  be  due  to  three  causes. 
It  may  be  primary  in  the  stomach  ;  reflex,  as  in  renal 
calculus,  or  pregnancy  ;  or  it  may  be  cerebral.  At  other 
times  the  vomited  matter  is  faecal,  or  urinous  ;  or  it  may 
be  a  part  of  a  general  disturbance.  It  is  common  at  the 
outset  of  fever,  or  in  choleraic  diarrhoea ;  this  may  be  termed 
'  symptomatic  vomiting.^ 

*  Primary  vomiting '  may  be  due,  either  to  matters  taken 
into  the  stomach,  or  to  ideas  associated  with  them,  or  to 
some  condition  of  the  stomach  itself.  With  babies  it  is 
quite  common  to  see  vomiting  from  too  liberal  a  supply  of 
food,  the  excess  merely  being  rejected  and  the  remainder 
retained.  With  some  people  all  shell-fish  produce  vomiting 
without  any  apparent  explanatory  reason.  In  other  cases, 
some  special  article  of  food,  ordinarily  well-borne  by  others, 
is  always  productive  of  sickness.  Nauseating  articles  will 
lead  to  vomiting.  So  will  '  nauseating '  ideas.  Rats  are 
readily  eaten  when  prepared  as  rabbits,  and  enjoyed,  I  am 
told ;  but  the  announcement  of  the  real  nature  of  the 
palatable  viand  swiftly  produces  free  emesis. 

Then,  as  to  the  condition  of  the  stomach.  Vomiting  is 
common  with  all  morbid  conditions  of  it,  as  it  procures 
physiological  rest  for  the  viscus.  It  may  be  set  up  by 
merely  taking  food  into  the  stomach,  as  in  gastric  ulcer,  and 
acute  congestion  from  alcoholic  indulgence.  In  the  latter, 
there  is  '  morning  vomiting'  of  frothy  mucus  and  loathing  of 
food  (usually,  too,  a  foul  breath,  a  loaded  tongue,  and 
evidences  of  nervous  unsteadiness — together  with  the  un- 


THE  ALIMENTA R  Y  CA NA L,  1 03 

truthfulness  of  the  drunkard — are  found  with  it).  Gastric 
catarrh  is  not  always  alcoholic,  and  the  food  may  be  re- 
turned covered  with  mucous  slime.  Here  time  must  have 
elapsed  for  the  mucous  covering  to  be  formed.  Immediate 
vomiting  is  due,  either  to  gastric  ulcer,  or  congestion  of  the 
stomach,  or  some  toxic  irritant.  In  the  latter  case  it  is 
suddenly  developed,  and  may  readily  pass  away.  In  ulcer 
the  opposite  is  the  case,  as  it  is  a  chronic  affection.  When 
the  stomach  is  at  rest  and  alkaline,  then  the  ulcer  does  not 
make  itself  felt.  But  let  food  be  taken,  and  then  the 
gastric  movements  begin  dragging  on  the  base  of  the  ulcer, 
and  the  acid  gastric  juice  is  poured  out ;  and  betwixt  the 
two  acute  pain  is  produced.  Vomiting  by  placing  the 
stomach  at  rest,  in  both  ways,  anatomically  and  physiologi- 
cally, at  once  gives  relief.  Consequently,  it  has  a  high 
diagnostic  value,  this  sudden  ease  after  vomiting  is  set  up. 
In  cancer  of  the  stomach  the  pain  is  not  so  strictly  related 
to  the  taking  of  food,  nor  so  pronouncedly  relieved  by 
vomitingr. 

The  matter  vomited  is  often  instructive.  When  it  con- 
sists of  foecal  matter  it  tells  of  intus-susception  above  the 
ilio-coecal  valve,  or  of  a  perforating  ulcer  between  the 
stomach  and  the  transverse  colon.  There  is  '  stercoraceous  ' 
vomiting  here.  In  some  chronic  renal  conditions  the  vomited 
matter  is  distinctly  urinous  in  odour  ;  this  is  '  ureemic  '  vomit- 
ing. Sometimes  bile  is  mixed  with  the  vomit ;  it  may  be 
due  to  liver  disorder,  but  bile  is  often  thrown  up  when  the 
act  of  vomiting  is  severe  or  prolonged.  Blood  is  not  un- 
common, especially  in  yellow  fever.  The  '  Black '  vomit 
is  a  symptom  of  the  worst  prognostic  omen.  '  Coffee- 
ground  '  vomit  may  be  due  to  a  congestive  outpouring,  or  to 
a  minute  hgemorrhage.  Blood  of  high  colour  tells  of  an 
ulcer  eroding  a  blood-vessel,  or  acute  congestion.  It  may 
be  a  form  of  vicarious  menstruation.  Indeed,  in  females, 
it  is  well  to  see  whether  the  hematemesis  be  rhythmic, 
coming  on  at  intervals,  corresponding    to   the    catamenial 


I04  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

periods,  especially  if  the  menses  be  irregular.  Pus  may 
be  vomited  from  an  abscess,  usually  in  the  liver. 

Vomiting  may  be  due  to  cough.  Great  depression  of  the 
diaphragm  with  the  action  of  the  abdominal  muscles  in 
severe  cough  may  lead  to  sickness. 

'  Keflex  '  vomiting  is  due  to  irritation  elsewhere.  A  blow 
on  the  testes  usually  leads  to  nausea  and  vomiting.  The 
pregnant  uterus  causes  vomiting,  espcially  in  the  morning, 
until  it  has  escaped  from  the  cavity  of  the  pelvis  into  the 
abdomen,  when  the  vomiting  ceases,  A  tender  ovary 
usually  causes  nausea  with  retching  and  vomiting  ;  and  the 
'  ovarian '  vomiting  is  that  form  found  in  younger  women, 
which  is  often  persistent,  producing  great  suffering,  and 
which  is  often  spoken  of  as  '  inflammation  of  the  stomach.* 
Unless  its  origin  be  remembered,  it  is  most  intractable  to 
treatment.  Then  a  calculus  in  the  pelvis  of  the  kidney  is 
usually  accompanied  by  vomiting,  which  is  reflex,  and 
which  has  a  high  diagnostic  value.  Inflammation  of  the 
peritoneum  will  give  rise  to  vomiting,  even  when  the  gastric 
fold  of  this  serous  membrane  is  not  the  seat  of  the  in- 
flammatory process.  Abdominal  wounds  often  give  rise  to 
vomiting,  as  do  loads  in  the  bowels.  This  is  '  sympathetic ' 
vomiting,  and  is  a  variety  of  '  reflex  '  vomiting. 

'  Cerebral '  vomiting  is  due  to  some  morbid  condition  of 
the  brain.  Its  leading  characteristic  is  freedom  from  nausea 
or  sickness.  It  comes  on  *  very  suddenly  without  any  pre- 
vious sickness.' — Abercrombie.  It  may  be  set  up  when 
the  patient  raises  the  head  from  the  pillow.  'Cerebral' 
vomiting  is  not  much  discussed  in  works  on  the  brain  and 
its  diseases  at  present.  Concussion  of  the  brain  sets  up 
vomiting  very  frequently,  and  as  a  symptom  thereof,  sick- 
ness is  suggestive.  Sickness  is  somehow  linked  with 
hemicrania.  Romberg  says  of  cerebral  vomiting,  the  hori- 
zontal position  relieves  it ;  there  is  no  premonitory  nausea ; 
no  retching,  the  contents  of  the  stomach  coming  up  quite 
easily  ;  while  there  are  usually  constipation,  irregular  action 


■  THE  ALIMENTARY  CANAL.  105 

of  the  heart,  with  symptoms  referable  to  the  head.  Sea- 
sickness has  got  to  find  its  satisfactory  explanation.  Whether 
it  is  cerebral  or  not  is  unknown.  Certainly  the  nausea  linked 
with  it  points  elsewhere.  Vomiting  is  set  up  often  by  vertigo 
in  many  cases.  '  Sea-sickness  '  is  set  up  by  the  movements  of 
the  came],  the  'ship  of  the  desert,'  with  some  persons.  Vomit- 
ing maybe  excited  by  a  foreign  body  in  the  ear.  Romberggives 
a  case  where  it  was  very  severe  from  pressure  on  the  vagus. 

Nausea. — A  feeling  of  nausea — that  is,  an  inclination  to 
be  sick — is  usually  the  precursor  of  vomiting  (except  when 
'  cerebral  ^) ;  or  it  occurs  without  vomiting  under  lesser 
exciting  causes.  When  the  alimentary  canal  is  disordered, 
nausea  is  a  very  common  occurrence.  It  is  accompanied  by 
a  loathing  of  food,  or  even  of  the  idea  of  food  at  times  ;  and 
is  the  means  by  which  the  digestive  organs  secure  physio- 
logical rest  for  themselves  when  unequal  to  carrying  on 
their  function.  It  is  also  experienced  in  a  great  degree  in. 
those  cases  of  ovarian  and  uterine  trouble  which  give  rise 
to  vomiting.  It  will  be  spoken  of  again  in  Chapter  VIII.;  it 
is  mentioned  here  mainly  in  relation  to  vomiting  and  loss  of 
appetite,  as  a  means  of  securing  rest  for  the  digestive  organs* 

Appetite. — This  is  the  sensation  of  desire  for  food.  It 
may  be  lost,  or  it  may  be  inordinate  and  morbid. 

What  hunger  and  appetite  depend  upon  is  rather  a 
matter  of  speculation  still,  than  a  portion  of  what  has  been 
determined.  They  are  not  convertible  terras.  The  desire  for 
food  is  '  appetite '  as  ordinarily  spoken  of ;  and  when  this 
sensation  is  acute,  it  is  called  *  hunger.'  But  a  person  may 
be  compelled  to  fast  until  all  appetite  for  food  has  passed 
awaj;",  and  a  sick  headache  has  taken  its  place.  This  is 
specially  liable  to  occur  with  those  persons  who  require 
food  at  frequent  intervals,  and  therefore  with  women.  Some 
require  food  in  small  quantities  and  at  frequent  intervals ; 
these  are  persons  whose  digestive  organs  will  not  bear  much 
strain.  Others  there  are,  usually  robust  men  with  square 
abdomens,  who  do  not  care  for  food  frequently,  but  who 


io6         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

like  a  good  meal  when  they  are  about  it.  There  is  some 
analogy  betwixt  these  two  classes  of  beings  and  locomotives. 
One  steam-engine,  which  is  engaged  in  running  short  jour- 
neys, has  a  small  tender,  and  can  carry  but  a  small  amount 
of  fuel,  necessitating  frequent  replenishing.  The  luggage 
engines,  and  the  express  engines  for  long  runs,  have  larger 
tenders  carrying  huge  quantities  of  fuel,  so  as  not  to  require 
refilling  at  short  intervals.  It  is  much  the  same  with 
human  beings.  The  capacity  of  the  digestive  organs  is  not 
exactly  commensurate  with  the  girth  of  the  individual ;  but 
there  is  a  general  relation.  Persons  with  capable  digestive 
organs  usually  have  a  large  abdomen — i.e.,  a  large  tender. 
Consequently  there  is  the  ordinary  '  appetite '  of  the  indi- 
vidual to  be  borne  in  mind  when  inquiries  as  to  its  varia- 
tions are  being  instituted.  Unfortunately  for  many  persons, 
their  appetite  remains  good  and  even  keen  when  the  real 
demands  of  the  system  are  comparatively  small ;  and  in 
consequence  they  suffer  from  repletion  with  biliousness,  or 
from  gout  in  its  wake.  This  is  well  seen  in  long  spells  of 
wet  weather,  when  persons  are  prohibited  from  taking  their 
usual  exercise.  They  are  confined  to  the  house,  yet  the 
appetite  remains  unimpaired ;  and  then  some  consequence 
of  this  repletion  follows.  One  gets  an  attack  of  acute  gout; 
another  has  the  tense  artery  of  lithiasis;  while  a  third  has  a 
yellow  shade  on  the  tongue,  and  is  bilious.  These  various 
conditions  were  very  prevalent  in  the  long  rains  of  the 
past  winter  (1882-83).  When  a  person  much  indoors  goes 
for  a  walking  tour,  or  even  goes  to  the  seaside,  and  is  out 
much  in  the  air,  then  increased  oxidation  leads  to  a  whetting 
of  the  appetite.  It  is  like  a  fire  that  is  burning  feebly, 
because  partially  choked  with  its  own  ash ;  give  it  a  poke, 
and  stir  away  the  accumulation  of  ash,  and  then  the  fire 
burns  up.  The  physiological  relations  of  appetite  must  be 
borne  in  mind  in  the  inquiries  made.  The  appetite  may  be 
good,  indifferent,  capricious,  dainty,  or  lost  (anorexia) ;  or 
be  excessive  (bulimia). 


THE  ALIMENTARY  CANAL.  107 

Persons  vary  much.  One  '  can  eat  anything  that  comes 
in  his  way/  If  the  appetite  for  food  be  there,  it  matters 
little  what  that  food  is,  whether  appetizing  or  not. 
Others,  again,  like  the  gazelle,  are  '  dainty  feeders ;'  their 
food  must  be  nicely  dressed  and  neatly  served  up,  or  they 
revolt  at  it.  It  is  also  well  in  such  cases  that  the  food  be 
offered  in  small  quantities  only ;  large  quantities  of  food 
take  away  their  appetite  ('  outface '  them,  to  use  a  north- 
country  expression).  When  ill  or  out  of  sorts,  this  dainti- 
ness of  the  appetite  becomes  very  marked.  The  dainty 
child  (not  necessarily  '  a  spoiled  child  ')  stood  a  poor  chance 
in  the  old  days,  when  food  was  both  coarser  and  less  neatly 
prepared  than  now.  The  multiparous  mother  looks  on  her 
numerous  brood  at  breakfast,  her  eye  watching  the  efforts 
of  each  with  delight  in  proportion  to  its  capacity,  and  en- 
courages them  ail  *  to  work  away,'  as  if  they  were  dutifully 
discharging  a  task.  During  the  period  of  growth,  when  the 
demands  of  the  tissues  are  great,  the  appetite  is  vigorous, 
except  when  there  is  '  acute  growth,'  and  then  the  appetite 
is  lost  in  the  general  malaise.  So  after  a  fever  or  other  acute 
disease,  the  prowess  of  the  individual  as  a  '  trencherman  '  is 
often  surprising. 

In  illness,  the  appetite  becomes  a  matter  of  much  import- 
ance. If  the  patient  can  eat,  then  the  outlook  is  bright ;  if 
the  appetite  falls  off,  so  the  prospect  darkens.  In  illness, 
and  especially  acute  disease,  the  daily  fluctuations  of  the 
appetite  are  eagerly  watched.  There  is  one  point  about  the 
appetite  in  early  phthisis  which  is  not  generally  known,  yet 
it  is  interesting.  Loss  of  appetite  is  often  a  symptom,  and 
an  evil  symptom,  especially  where  there  is  a  drain  upon  the 
system,  as  severe  night-sweats ;  for  between  the  two  the 
patient  falls  away,  with  the  risk  of  softening  in  the  consoli- 
dated lung-apex  ('  becoming  tuberculous,'  as  Niemeyer  puts 
it).  Here  experience  has  told  me  that  the  arrest  of  the 
hydrosis  is  followed  by  a  return  of  the  appetite  in  a  few 
days.     It  would  seem  that  when  the  blood-salts  are  drained 


1 08         PHYSIOLOGICAL  FA CTOR  IN  DIA GNOSIS. 

away  in  sweat  ('the  phosphates,  the  chlorides,  and  the 
sulphates  of  the  alkalies '),  the  appetite  goes  with  them. 
Check  the  night-sweats,  say  b}'^  full  doses  of  atropia,  and 
with  them  this  drain,  and  the  appetite  quickly  returns. 
The  appetite  (with  the  pulse  and  the  sleep)  has  to  be  care- 
fully watched  in  acute  disease,  as  telling  how  the  patient  is, 
which  is  diagnosis  surely,  if  not  diagnosis  of  the  nature  of 
the  disease. 

Appetite  is  linked  with  the  emotions.  When  all  is  well, 
it  is  keen.  Good  news  whets  the  appetite,  and  inclines 
the  hearer  to  give  a  feast.    Bad  news  palsies  the  appetite. 

'  Read  o'er  this. 
And  after  this  ;  and  then  to  breakfast  with 
What  appetite  you  have,' 

said  King  Henry  to  Wolsey ;  and  the  prospect  of  eating  lost 
its  charms,  we  may  be  sure.  In  the  same  way,  mere  per- 
sisting mental  emotion  will  destroy  the  appetite,  just  as  it 
robs  the  individual  of  sleep.  Some  little  time  ago  a  case  of 
anorexia  with  vomiting,  especially  at  the  times  when  the 
catamenia  (which  had  disappeared)  should  have  showed 
themselves,  came  under  my  notice  in  a  young  girl  who  had 
been  disappointed  in  love.  When  the  appetite  is  lost  with- 
out obvious  reason,  it  is  well  to  apprehend  some  mental  cause. 
Hunger. — Hunger  is  a  more  pronounced  condition  of  the 
normal  appetite.  '  As  hungry  as  a  hunter '  tells  of  the  effect 
of  long  severe  exertion  and  fasting  upon  the  appetite.  Such 
is  the  effect  of  exertion  with  increased  oxidation.  The 
gourmand  seeks  an  appetite  by  design,  and  resorts  to  toil, 
the  great  appetiser.  Just  as  a  good  meal  causes  a  pleasant 
psychical  attitude — as  the  establishment  of  dinners  for 
charitable  institutions  testifies — so  fasting  is  linked  with 
shortness  of  temper.  *  A  hungry  man  is  an  angry  man '  is 
an  old  saying,  and  hunger  is  readily  transformed  into  anger. 
'  Hunger  is  the  mother  of  impatience  and  anger,'  said  Zim- 
merman— an  axiom  it  is  well  to  bear  in  mind;  for  the 
medical   man,  of  all  men,  should  be  a  student  of  human 


THE  ALIMENTARY  CANAL.  109 

nature.  With  women  it  is  changed  into  a  headache  with 
irritability.  Appetite  to  the  invalid  and  the  ailing  is  what 
hunger  is  to  the  robust — an  unusual  and  pleasant  craving 
for  food. 

Anorexia. — This  is  loss  of  appetite  more  or  less  complete. 
It  occurs  in  the  onset  of  fevers  and  inflammatory  conditions, 
and  is  present  in  many  less  acute  conditions.  Anorexia  is 
common  with  different  forms  of  mental  aberration ;  in  some 
eases,  indeed,  when  the  real  necessity  for  food  is  great  and 
imperious.  It  is  also  common  with  what  are  termed 
'  hysterical '  affections.  It  is  also  found  in  chronic  condi- 
tions, as  pernicious  an?emia.  It  is  seen  in  some  cases  of 
pulmonary  phthisis,  and  has  a  malign  influence  upon  the 
nutrition  of  the  diseased  portion  of  lung.  It  is  also  found  in 
some  '  cases  of  fatal  disease  occurring  in  persons  of  middle  or 
advanced  life,  the  pathological  character  of  which  is  not  as 
yet  fully  established,  but  which  is  probably  seated  in  the 
glands  secreting  the  gastric  and  intestinal  digestive  fluids.' — 
Flint.  The  recovery  of  the  appetite  is  the  evidence  of 
convalescence  setting  in  after  acute  disease.  When  the 
appetite  suddenly  disappears  in  convalescence,  it  is  probable 
the  patient  has  had  too  much  food  (a  '  surfeit '),  or  it  has 
been  of  improper  or  satiating  character.  After  a  day  or  two 
of  fasting  the  appetite  returns. 

Anorexia  is  a  phenomenon  worth  studying.  The  impres- 
sion is  general  that  the  loss  of  appetite  is  an  unmixed  evil, 
and  consequently  the  demand  for  an  appetiser  is  prompt  and 
unhesitating.  This  is  irrational,  and  often  unwise.  The 
loss  of  appetite  is  nature's  treatment  in  certain  cases.  For 
instance,  the  liver  is  upset,  and  the  appetite  disappears. 
Here  the  loss  of  appetite  permits  of  the  embarrassed  organ 
recovering  its  lost  functional  activity.  By  such  means, 
indeed,  the  liver  secures  physiological  rest.  It  cannot  get 
relief  any  other  way.  The  stomach  can  get  rest  by  vomiting, 
the  bowels  by  the  ejection  of  their  contents  in  free  evacua- 
tions, but  the  liver  has  no  such  ready  means  of  obtaining 


no         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

relief  when  embarrassed.  So  the  outcome  of  a  loaded  or 
deranged  liver  is  loss  of  appetite,  which  is  not  to  be  looked 
upon  as  a  pure  evil  to  be  fought  with  by  bitters.  The 
simplest  instance  of  liver-anorexia  is  the  loss  of  appetite 
after  a  surfeit,  whether  in  child  or  adult.  The  liver  is 
choked  with  sugar  and  albuminoids,  and  requires  time  to 
deal  with  them.  More  food  will  only  add  to  the  embarrass- 
ment of  the  viscus,  so  the  outer  danger  signal  is  hoisted,  to 
use  a  railway  term.  The  signal  is  up  against  more  food. 
To  attempt  to  force  the  appetite  in  such  a  case  is  as 
irrational  as  would  be  the  conduct  of  an  engine-driver  if  he 
ran  past  a  signal  standing  against  him.  An  avoidable 
accident  is  highly  probable  as  much  in  one  case  as  the 
other. 

Anorexia,  then,  may  be  truly  physiological,  and  not 
pathological  at  all. 

Bulimia. — The  opposite  condition  of  bulimia  is  scarcely 
unphysiological  when  the  demand  for  food  is  great,  i.e. 
when  the  tissues  are  hungry.  Here  the  needs  of  the  system 
speak,  or  find  expression  in  a  craving  appetite  to  supply  the 
food  the  body  requires.  Convalescence  from  acute  disease, 
which  has  led  to  wasting,  and  growth  entail  bulimia  as 
their  voice — their  cry  for  food.  But  under  other  circum- 
stances bulimia  is  a  disease.  It  is  set  up  commonly  by 
some  morbid  condition  of  the  mucous  lining  of  the  alimentary 
canal,  intensifying  the  normal  hunger,  or  appetite.  It  is  not 
uncommon  after  measles,  or  other  ailments  of  childhood ; 
and  is  seen  in  some  cases  of  advanced  phthisis.  More  food 
is  taken  than  can  be  digested  ;  the  blood  is  ill-fed ;  the 
craving  increases ;  and  if  the  false  appetite  is  complied  with, 
the  patient  soon  sinks. 

Perverted  appetite  is  of  lesser  and  greater  proportions  in 
various  cases.  It  is  seen  in  pregnant  women  who  crave 
after  all  sorts  of  odd  things.  In  hysterical  girls  who  hanker 
after  slate  pencils,  chalk,  or  coals.  It  is  seen  in  the  desire 
for  condiments,  for  vinegar  or  salt,  in  dyspeptics  who  should 


THE  ALIMENTAR  Y  CANAL.  r  1 1 

avoid  such  things.  In  insanity,  sometimes,  the  most  loath- 
some matters  are  eaten  freely,  A  '  craving '  appetite  is 
sometimes  seen  to  precede  an  acute  attack  of  gout.  In 
some  epileptics  it  is  the  forerunner  of  a  fit ;  and  if  it  can  be 
checked,  the  fit  may  be  averted. 

Dyspepsia. — The  outlying  symptoms  of  dyspepsia  are 
legion,  and  cannot  be  discussed  here.  The  essential  features 
only  can  be  given.  Dyspepsia  is  '  difficult  digestion,'  known, 
commonly  as  '  indigestion.'  To  comprehend  dyspepsia  it  is 
well  to  think  of  '  the  digestive  act/  and  its  various  steps. 

Digestion  is  disintegration  and  solution.  Starch  is  con- 
verted into  grape  sugar ;  proteids  (insoluble  albuminoids) 
into  peptones  (soluble  albuminoids).  Food  must  be  made 
soluble  to  pass  out  of  the  alimentary  canal  into  the  portal 
vein.  Having  reached  the  blood,  these  materials  would 
escape  at  the  kidneys  (as  they  do  in  some  forms  of  albumi- 
nuria and  glycosuria)  unless  once  more  made  insoluble.  So 
they  are  turned  back  into  glycogen  (animal  starch)  and  into 
proteids.  The  first  is  the  fuel  of  the  body,  the  latter  the 
nutriment  of  the  tissues.  Fat  undergoes  no  change  beyond 
emulsification  into  very  fine  particles,  so  as  to  be  able  to 
enter  the  mouths  of  the  lacteals. 

Now  the  first  act,  or  solution  in  the  alimentary  canal,  is 
*  primary  digestion.'  When  it  is  imperfectly  performed  two 
main  symptoms  are  manifested,  viz.,  pain  and  distension. 
The  late  Arthur  Leared  thought  pain  indicated  deficiency 
of  gastric  juice  (and  the  relief  from  pain  often  given  by  a 
dose  of  pepsin  corroborates  this  view) ;  while  distension,  he 
held,  was  the  evidence  of  imperfect  muscular  action  in  the 
stomach. 

The  pain  is  felt  in  the  stomach  itself,  sometimes  referred 
to  the  mid-sternum.  Or,  in  women,  chiefly,  it  is  felt  in  the 
back  '  betwixt  the  shoulder  blades,'  they  will  tell  you.  It 
is  more  or  less  acute  ;  and  is  either  free  from,  or  complicated 
with  a  sense  of  distension.  Sometimes  it  is  set  up  imme- 
diately ;  while,  at  other  times,  it  comes  on  at  a  later  period. 


112         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

When  the  discomfort  is  not  felt  for  an  hour  and  a  half  or 
two  hours  after  a  meal,  then  it  is  held  to  be  '  duodenal,'  be- 
cause the  time  corresponds  with  the  passing  of  the  contents 
of  the  stomach  into  the  duodenum.  It  may,  however, 
point  to  cancer  of  the  pyloric  ring. 

Sense  of  distension,  or  flatulence,  is  linked  with  defective 
muscular  action.  It  may  be  experienced  in  the  stomach 
soon  after  food  is  taken ;  or,  later  on,  in  the  intestines.  In 
gastric  catarrh,  especially  when  due  to  the  venous  fulness 
of  an  injured  or  failing  heart,  this  sense  of  distension  is  ever 
present,  in  fasting  as  well  as  after  food.  Sometimes  the 
mucous  membrane  gives  off  gas  very  freely.  The  rolling  of 
the  intestines  (borborygmus)  is  audible,  or  the  flatus 
comes  up  the  gullet  in  roar  after  roar,  in  some  cases  so  loud 
and  so  long  continued  as  to  be  surprising.  Or  the  flatus 
may  pass  per  anum.  The  '  bowels  yearn '  indeed  in  some 
persons  with  emotion.  And  the  ancient  Hebrews  (the  most 
dyspeptic  race  upon  earth)  seem  to  have  been  especially 
liable  to  straining  of  the  bowels  upon  emotion.  'The 
muscular  walls  of  the  alimentary  canal  seem  frequently  to 
be  excited  to  increased  action  by  agitating  emotions  ;  but  it 
may  be  doubted  how  far  this  is  a  primary  effect  of  the 
mental  state,  or  how  far  it  is  consequent  upon  the  influence 
of  that  state  upon  the  secretions  poured  into  the  canal.' — 
Carpenter.  Pain  and  distension  are  the  two  great  indices 
of  '  primary  indigestion.' 

'  Secondary  digestion '  is  applied  to  the  further  elaboration 
of  the  albuminoids  (mainly)  in  the  liver.  From  the  albu- 
minoids furnished  to  the  portal  vein  the  liver  elaborates  the 
serum-albumen  of  the  liquor  sanginis,  the  pabulum  of  the 
tissues.  The  excess  (or  luxus  consumption)  or  the  imperfect 
products  of  digestion  are  broken  up  into  bile  acids  (glyco- 
cholic  and  taurocholic),  both  of  which  contain  nitrogen, 
while  one  (taurocholic)  contains  sulphur.  Or  they  are  sent 
on  a  retrograde  metamorphosis  through  the  series  tyrosin, 
leucin,  creatine,  and  creatinine,  the  early  forms,  to  uric  acid 


THE  A LIMENTA RY  CANAL.  113 

and  urea,  the  advanced  forms  of  waste.  Urea  is  tlie  main 
constituent  of  a  fluid  urine.  The  solid  urine  of  birds  and 
reptiles  consists  on  the  other  hand  of  urates.  In  human 
beings  the  liver  sometimes  makes  urates  freely,  and  the 
condition  is  known  as  lithiasis.  When  the  liver  drives  an 
excess  of  proteids  into  bile  acids,  then  the  condition  of 
cholsemia,  or  biliousness  is  produced.  Sometimes  this  is 
due  to  an  excess  of  proteids  beyond  the  requirements  of 
the  body ;  at  other  times  the  tissues  waste,  the  person  loses 
weight  while  there  is  cholsemia,  when  the  liver  does  not 
elaborate  the  proteids  into  serum-albumen  ;  but  drives  them 
all  downwards  into  bile  acids  or  urine  products.  (The 
young  pathologist  may  smile  here,  or  even  break  out  into 
derisive  laughter  !  but  the  practice  of  physic  is  not  confined 
to  histological  research.  When  he  can  put  up  '  a  liver-cell 
wasted  by  care/  or  '  liver-cell  of  cholasmia,'  perhaps  these 
conditions  may  dawn  upon  him.  Or,  possibly,  when  he  be- 
gins to  see  a  little  of  private  practice,  he  may  recognise  con- 
ditions which  do  not  provide  him  with  material  for  his 
microscopic  studies  ;  and  begin  to  find  out  that '  physiology ' 
is  not  mere  '  histology,'  though  it  has  been  too  long  the 
practice  to  confound  the  two:  making  the  latter  synonymous 
with  the  former.  A  man  may  be  a  skilful  histologist  and 
familiar  with  embryology,  and  yet,  not  be  a  sound  physiolo- 
gist, let  alone  a  safe  physician.) 

Or,  in  other  cases,  a  tremendous  output  of  white  urates 
marks  the  later  hours  of  the  digestive  act.  Here,  also,  there 
is  imperfect  tissue- nutrition.  There  are  no  local  symptoms 
of  this,  unless  it  be  irritation  of  the  urinary  passages.  But 
both  in  cholseraia  and  in  the  form  of  lithiasis,  as  well  as  in 
mere  chronic  forms  of  lithiasis  or  gout,  these  are  evidences 
of  the  system  being  under  a  toxic  influence.  Especially 
does  the  nervous  system  suffer.  Headache,  vertigo,  anoma- 
lous pains,  a  sense  of  ill-being  (instead  of  the  well-being- 
felt  normally  after  food),  disturbance  of  the  posterior  cere- 
bral lobes  in  morbid  sensations,  are  manifested.     There  is 

8 


114        PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

always  panphobia,  an  impression  of  impending  evil,  no 
matter  what  the  especial  ailment.  The  action  of  the  heart 
is  commonly  disturbed,  and  there  may  be  palpitation 
(common  with  lithtemia),  or  depression  of  the  heart's  action 
(the  common  associate  of  cholsemia). 

Such  then  are  the  local  and  general  semeia  of  dyspepsia 
or  indigestion. 

Vertigo. — Vertigo,  '  dizziness,'  or  '  swimming  in  the  head,' 
is  a  symptom  frequently  met  with  in  indigestion.  It  tells 
that  the  pons,  or  the  cerebellum  is  disordered.  Still,  '  gastric 
vertigo '  is  not  common,  when  we  reflect  how  infinite  are 
gastric  disturbances.  'Disordered  stomachs  and  feeble, 
weary  brains  would  seem  to  afford  the  most  favourable  con- 
ditions for  the  generation  of  this  neurosis,  yet  they  do  not 
seem  'per  se  sufficient.' — Handfield  Jones.  It  comes  on  after 
a  meal,  and  is  usually  relieved  by  emptying  the  stomach 
(vomiting) ;  though  sometimes  its  duration  is  more  per- 
sistent. 

Pyrosis. — Pyrosis,  or  'water-brash,'  is  the  eructation  of  an 
acrid  fluid  from  the  stomach.  It  is  not  '  heartburn,'  though 
there  may  be  *  heartburn '  present  as  well  in  some  cases. 
There  is  a  recurrent  reffur^itation  of  a  fluid  which  scalds 
the  gullet,  and  even  the  fauces.  It  is  sometimes  due  to  the 
formation  of  a  fatty  acid  of  irritant  properties,  as  butyric  or 
allied  acid.  At  other  times  the  fluid  is  alkaline.  Fluid  is 
here  eructated  without  food.  "When  the  food  is  regurgitated, 
as  in  the  ruminants,  it  is  rather  pleasant  to  the  taste  than 
otherwise.    Such  rumination  is  a  peculiarity,  not  a  disease. 

The  next  matter  to  attract  our  attention  is  the  intes- 
tinal canal,  with  its  disturbances,  of  which  the  first  is 
colic. 

Colic. — Colic,  or  '  gripes,'  is  due  to  a  spasm  of  the  muscu- 
lar wall  of  the  intestines,  producing  acute  pain,  with  or 
without  flatulence.  It  is,  indeed,  a  '  cramp.'  Sometimes  it 
is  mainly  gastric,  when  set  up  by  improper  food,  as  greens, 
especially  when  taken  cold.     It  may  be  excited  by  some 


THE  ALIMENTARY  CANAL.  115 

irritant,  as  certain  cathartic  drugs.  The  pain  may  double 
the  patient  up,  and  the  arms  are  pressed  over  the  seat  of 
suffering,  and  tightly,  too.  In  peritonitis,  the  patient  is  at 
rest  with  his  knees  up,  and  the  respiration  almost  entirely 
thoracic,  so  as  to  limit  movement  in  the  inflamed  serous 
membranes  ;  while  in  colic,  pressure  is  grateful.  There  may 
be  no  desire  to  empty  the  bowels  j  but  in  other  cases  there 
is  tenesmus.  *  It  is  only  the  last  rapid  terminal  undula- 
tions which  are  manifested  by  a  frequent  desire  to  evacuate 
the  rectum.' 

Colic,  or  griping,  is  often  the  result  of  a  dose  of  purgative 
medicine.  Some  people  cannot  take  any  laxative  without 
such  spasm  of  the  intestine  being  set  up.  Frequently  the 
pain  is  due  to  abortive  attempts  to  empty  the  gut.  When 
the  bowel  can  send  on  its  contents,  less  pain  is  the  result. 
When,  then,  the  patient  complains  of  much  griping,  this 
may  be  due  to  imperfect  action  of  the  bowels,  rather  than  to 
excessive  catharsis.  It  may  be  necessary  to  increase  the 
dose  of  laxative  ;  not  to  decrease  it.  Some  patients  suffer  so 
much  spasm  when  the  vermicular  action  of  the  bowel  is 
excited,  that  a  sfedative  with  the  purgative  is  indicated. 

Severe  local  pain  may  point  to  an  ileus  in  the  small 
intestine ;  or  to  a  twist  of  the  colon  ;  to  stricture,  spasmodic 
or  organic;  or  to  a  hernia.  The  peculiarity  of  intestinal 
pain  is  that  it  is  referred  to  the  umbilicus ;  just  as  the  pain 
of  the  spinal  meninges,  being  inflamed,  gives  the  impression 
of  a  tight  cord  round  the  body  ('  girdle  pains  ').  The  refer- 
ence of  the  pain  to  the  navel  is  a  valuable  guide  as  to  what 
to  look  for. 

Lead  colic  is  a  severe  affection,  which  carries  with  it  the 
'  lead-line  on  the  gums  'as  its  most  trustworthy  evidence. 

Gastralgia  is  a  recurrent  neuralgic  state.  Here  the 
recurrent  pain  is  referred  to  the  stomach.  At  other  times 
the  pain  is  in  the  bowel.  Like  neuralgic  affections,  it  is 
likely  to  be  '  unilateral.'  The  superior  mesenteric  plexus  and 
its  ramifications  are  its  seat.     Hand  field  Jones  relates  of  a 

8—2 


ii6         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS.  \ 

case  :  '  At  4  a.m.  she  was  attacked  with  severe  pain  in  the 
left  lower  part  of  the  abdomen.  This  did  not  last  an  hour ; 
but  the  next  night  it  returned  nearly  at  the  same  time,  and 
was  exceedingly  severe  for  many  hours.  The  pain  spread 
about  a  good  deal,  and  made  her  feel  very  faint.  After 
it  had  gone  off,  there  was  no  tenderness  or  uneasiness  at 
all,  nor  anything  abnormal  in  the  abdomen,  which  was  lax 
and  soft.' 

Tenesmus. — This  is  the  feeling  or  wish  to  go  to  stool, 
excited  by  the  presence  of  any  substance  in  the  sensitive 
lower  portion  of  the  rectum.  Piles  will  excite  it ;  so  may  a 
polypus  in  the  rectum.  Sometimes  it  is  due  to  a  hard  foecal 
mass  in  the  lower  bowel.  Then  the  feeling  is  persistent,  be- 
cause unrelieved  by  the  act  of  deffecation.  Fluid  motions 
alone  can  pass,  and  consequently  there  is  apparent  diarrhoea. 
Persisting  tenesmus,  unrelieved  by  going  to  stool,  should  at 
once  put  the  practitioner  on  the  alert.  Tenesmus  may  be 
set  up  by  diarrhoea ;  and  is  one  of  the  greatest  causes  of 
suffering  in  dysentery. 

It  may  be  confounded  with  'rectal  neuralgia.'  Mr. 
Ashton  describes  such  a  case  :  '  He  complained  of  great  pain 
at  the  fundament  occurring  daily,  and  continuing  for  some 
hours,  not  induced  or  aggravated  by  defsecation.'  Here  the 
recurrent  character  of  the  pain  tells  of  its  nature. 

Pain  on  Defsecation. — This  may  be  due  to  fissure  of  the 
anus,  or  to  spasm,  or  an  inflammatory  condition  of  the 
bowel,  or  an  abscess  in  or  near  it.  In  women  it  is  often  due 
to  a  tender  ovary,  or  the  uterus  may  be  at  fault.  A  foreign 
body  in  the  rectum  may  be  the  cause. 

Pruritus  Ani. — Itching  at  the  seat  may  be  due  to  seat- 
worms ;  or  it  may  be  due  to  some  modifications  of  the 
contents  of  the  bowel.  When  not  due  to  seat-worms  it  is 
commonly  an  indication  of  a  disordered  liver.  It  may  have 
other  local  causes  than  '  thread  worms,'  as  eczema.  m 

The  periodical  emptjang  of  the  bowels  is  essential  to  health. 
The  interval  which  occurs  betwixt  each  act  of  deftecation 


THE  ALIMENTARY  CANAL.  117 

varies  with  different  persons.  Two  or  three  times  per  diem 
does  not  constitute  'diarrhoea'  with  some  persons;  nor  an 
action  once  a  week  '  constipation '  in  others.  When  the 
action  is  at  long  intervals — and  an  action  once  a  week 
would  constitute  positive  relaxation  of  the  bowels  with  some 
few  persons — the  term  *  obstipation'  is  used.  With  most 
persons  the  bowels  move  once  daily;  with  others,  twice. 
An  evacuation  at  night,  as  well  as  in  the  morning,  is 
desirable  if  there  be  any  source  of  trouble  in  the  pelvis.  The 
terms  used  for  the  action  of  the  bowels  are  '  regular,'  '  irregu- 
lar,' '  constipated,'  or  '  relaxed.' 

Regular. — This  term  is  used  when  the  bowels  move  at 
regular  intervals,  and  the  lower  bowel  is  kept  free  from  any 
load,  or  accumulation.  It  is  well  to  ascertain  what  is  the 
usual  interval  with  each  patient.  '  Regular '  is  an  elastic 
term  covering  many  variations,  if  accepted  from  the  patient 
without  correction ;  and  is  not  used  with  any  attempt  at 
precision  by  many  patients,  especially  among  women  of  the 
lower  classes. 

Irregular. — This  term  is  also  used  with  varying  meaning 
in  different  cases.  Usually  it  means  more  or  less  constipa- 
tion. Not  unfrequently  it  is  used  where  the  bowels  are 
locked  up  for  several  days,  and  then  are  relieved  by  purga- 
tion (spontaneous). 

Constipation. — This  is  a  lethargic  state  of  the  bowels  in 
which  they  are  not  sufhciently  emptied.  It  differs  from 
'  costiveness,'  where  there  are  scanty  fceces.  Sometimes  the 
ffBces  get  into  the  pouches  of  the  colon  and  are  passed  in 
rounded  masses  like  the  faeces  of  several  animals  (scybalse). 

When  constipation  is  present,  whether  with  indigestion 
or  any  other  malady,  relief  can  never  be  effectually  given 
until  the  bowels  are  educated  to  act  properly.  First,  there 
is  the  load  mechanically  interfering  by  pressure  upon  the 
viscera,  or  obstructing  the  descent  of  the  diaphragm;  con- 
sequently, in  emphysema  the  state  of  the  bowels  has 
much  to  do  with  the  comfort  or  discomfort  of  the  individual. 


iiS         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

Or  gases  or  offensive  matters  may  be  reabsorbed  from  the 
bowel.  A  form  of  anasmia  is  recognised  at  the  London 
Hospital  as  being  due  to  constipation,  the  offending  matters 
absorbed  from  the  gut  destroying  the  red  blood-corpuscles. 
It  is  sound  practice  always  to  regulate  the  action  of  the 
bowels :  no  matter  what  the  malady  complained  of  by  the 
patient.  This  can  always  be  done  by  perseverance  on  the 
part  of  the  doctor  and  the  patient,  both.  Many  cases  go  on 
unrelieved,  or  but  imperfectly  relieved,  because  the  medical 
man  is  careless,  or  timid,  or  does  not  grapple  with  the  case 
effectively  ;  while  in  other  cases  the  patient  is  at  fault,  either 
failing  to  carry  out  the  orders  given,  or  tiring  of  the  treat- 
ment. The  bulk  of  cases  of  confirmed  constipation  are  due 
to  one  or  other  of  these  causes,  or,  perhaps,  sometimes  to 
both  combined.  In  girls  the  bowels  are  often  allowed  to  go 
on  unrelieved  until  a  permanent  evil  has  resulted,  as  dis- 
location of  the  ovaries,  with  adhesions  forming  so  as  to  detain 
the  misplaced  ovary,  giving  rise  to  an  after-lifetime  of 
trouble;  or  the  uterus  suffers.  The  regular  action  of  the 
bowels  is  essential  to  health.  The  bowels,  too,  may  act 
well  in  health  and  be  deranged  by  some  malady,  as  an?emia, 
for  instance,  or  some  inflammation. 

Flatulence. — This  is  very  troublesome  often.  It  may  be  a 
persistent  matter,  as  in  atonic  conditions  of  the  bowels  ;  or 
it  may  only  be  found  after  a  meal  consisting  of  hot  fluids, 
as  is  common  with  women  after  tea.  '  I  believe  it  is  con- 
sidered by  some  of  our  best  authorities  as  highly  heretical 
to  hold  that  mucous  membranes  can  secrete  gas.' — Hand- 
field  Jones.  Yet,  as  he  points  out,  there  are  cases  where 
there  are  '  bursts  of  gastric  or  intestinal  flatulence.  It  seems 
as  if  one  might  almost  speak  of  a  gaseous  diarrhoea.^  Cer- 
tainl}',  all  intestinal  gas  does  not  seem  to  arise  from  the 
contents  of  the  bowels,  though  probably  the  oftensive 
gases  do.  Flatulence  as  a  '  neurosis  '  is  a  clinical  fact.  In 
some  thoracic  aftections,  flatulence,  interfering  with  the 
descent  of  the  diaphragm,  or  even  pushing  it  up,  is  a  great 


THE  ALIMENT AR  V  CANAL.  1 19 

source  of  suffering.  When  flatulence  is  in  the  small  in- 
testine, it  is  apt  to  give  rise  to  rumbling,  as  a  contraction  of 
the  bowels  moves  the  gas  (borborygmus)  ;  and  with  some 
females  this  is  very  audible  to  others  as  well  as  the  in- 
dividual. 

Relaxed. — Here  the  contents  of  the  bowels  are  passed  in  a 
fluid  state.  This  may  be  due  to  the  activity  of  the  bowel 
passing  on  the  food  so  quickly  that  the  fluid  portion  cannot 
be  absorbed ;  or  to  excessive  secretion  of  the  intestinal 
glands  :  or  both.  Lientery  is  the  term  used  when  the  food 
is  passed  per  anum  shortly  after  being  swallowed,  and 
practically  unchanged  by  the  digestive  act;  and  is  an 
instance  of  the  first.  The  diarrhoea  of  copious  watery  stools 
is  probably  the  latter,  chiefly  at  least. 

The  character  of  the  stools  should  be  examined  whenever 
there  is  any  question  as  to  the  nature  of  the  diarrhoea. 

Diarrhoea. — This  hyper-activity  of  the  bowel  may  have 
various  associations. 

It  may  be  due  to  irritant  matter  in  the  bowel,  setting  up 
excessive  secretion  with  increased  vermicular  action  for  its 
removal.  Here  it  is  a  physiological  diarrhoea.  (This  is  the 
form  of  diarrhoea  '  cured '  by  castor-oil.) 

It  may  be  a  catarrh  from  cold.  If  of  the  lower  bowel, 
mucus  will  be  present. 

Or  it  may  be  compensatory  to  arrested  renal  action,  the  fluid 
havino-  an  urinous  odour.  Such  diarrhoea  is  not  uncommon 
with  the  subjects  of  old-standing  renal  disease. 

In  dysentery  there  are  flakes  of  the  exfoliated  mucous 
membrane,  telling  of  the  mucous  inflammation  present. 

Or  it  may  be  due  to  ulceration  of  the  bowel,  which  may 
be  tubercular. 

The  Stools. — The  stools  may  be  '  fiitty,'  when  there  is 
disease  involving  the  head  of  the  pancreas,  and  the  fat  is 
not  emulsionized.  With  some  phthisical  patients  their 
cod-liver  oil  passes  en  masse,  unchanged  by  any  digestion. 

They  contain  mucus  in  muco-enteritis.     They  may  con- 


I20         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

tain  pus  when  an  abscess  bursts  into  the  bowels  as  a  liver- 
abscess. 

Or  the  food  may  appear  unacted  upon  when  there  is  an 
ulcer  betwixt  the  stomach  and  the  transverse  colon. 

The  stools  are  dark  and  offensive  in  certain  bilious 
derangements  ;  even  dark  and  tarry  when  old  secretion  from 
the  liver  is  passed ;  at  least,  so  old  practitioners  talk  and 
think,  perhaps  not  unwisely ! 

Or  they  may  be  pale,  as  in  the  white  stools  of  jaundice, 
indicating  lack  of  bile.  '  The  white-scour '  is  a  diarrhoea  of 
children  in  hot  climates,  where  the  bile  is  deficient.  In 
some  forms  of  diarrhoea,  and  notably  in  typhoid  fever,  the 
stools  contain  milk  curd.  (When  this  is  the  case,  it  is  well 
to  stir  some  farinaceous  matter  into  the  milk  to  prevent  its 
too  firm  curdling.  Or  some  chalk  in  cases  of  diarrhoea 
which  is  not  typhoid.) 

In  typhoid  fever,  the  stools  resemble  pea  soup,  and  are 
very  ofiensive.  Indeed,  the  character  of  the  motion  often 
plays  an  important  part  in  the  diagnosis. 

In  children,  the  stools  are  apt  to  be  claj^-coloured  in 
hydrocephalus,  or  '  green  as  grass,'  though  this  last  colour 
is  not  due  always  to  hydrocephalus ;  but  may  follow  a  dose 
of  calomel.  Grass-green  stools  usually  go  with  malnutrition. 

Then  the  stools  may  be  blackened  by  iron  taken  as  medi- 
cine ;  especially  when  the  iron  is  not  well-absorbed.  Such 
stools  often  cause  needless  alarm. 

The  stools  of  meat-eaters  are  usually  more  ofiensive  than 
those  of  vegetarians  ;  just  as  are  those  of  the  carnivora  as 
compared  to  the  herbivora.  A  farinaceous  dietary  with 
milk  will  usually  give  light-coloured,  and  comparatively 
inofiensive,  or  odourless  stools. 

Small  scanty  fluid  stools  ai'e  alone  possible  when  there  is 
a  mass,  whether  ftecal,  or  piles,  or  an  ovary,  or  even  the 
fundus  of  the  womb  is  pressing  into  the  anal  ring. 

Blood  is  found  in  the  stools  in  melrena  when  it  has  been 
mixed  high  up  in  the  bowels  and   blackened  by  the  intes- 


THE  ALIMENTAR  V  CANAL.  1 2 1 

tinal  gases.  Or  from  haemorrhoids,  or  anal  fissure.  Some- 
times it  comes  in  a  hot  gush  at  stool  from  the  rectal  lining 
membrane,  without  a  gross  lesion,  as  '  passive  hfemorrhage.' 
Or  it  may  be  clue  to  a  foreign  body  in  the  rectum. 

Relation  of  Bowels  to  Brain. — These  relations  are  interest- 
ing, curious,  and  often  of  practical  importance.  Disease  of 
the  brain  commonly  leads  to  lessened  vermicular  action  and 
constipation ;  while  emotion  may  cause  diarrhoea.  Fear 
may  relax  the  sphincter  without  affecting  the  f?eces.  Tuber- 
cular meningitis  with  diarrhoea  closely  simulates  typhoid 
fever.  A  sharp  purgative  will  often,  by  unloading  the 
bowel,  improve  the  circulation  through  the  brain. 

One  point  is  of  importance,  and  that  is  the  melancholic 
feelings  produced  by  a  load  in  the  colon,  and  relieved  by  its 
removal.  Schroeder  Van  der  Kolk  pointed  this  out  very 
clearly.  In  one  case  of  constipation  the  depression  of 
spirits  was  so  marked  that  I  felt  sure  there  was  some  pelvic 
cause.  The  reproductive  organs  were  examined  without 
result  by  Dr.  Broadbent ;  but  on  my  persisting  he  examined 
the  bowel  and  found  a  polypus,  which  was  removed  by 
Mr.  W.  F.  Teevan,  with  satisfactory  results.  It  is  in  a 
woman  of  highly  developed  nervous  system  that  such  reflex 
effects  may  be  looked  for.  Some  women  are  like  an  instru- 
ment so  highly  strung  the  least  touch  vibrates  throughout 
the  whole.  A  displaced  uterus  will  often  set  up  violent 
palpitation,  which  disappears  with  the  replacement  of  that 
viscus. 

Reflex  Constipation. — When  the  vermicular  action  of  the 
bowels  causes  pain,  it  is  apt  to  be  inhibited;  perhaps  without 
consciousness.  Thus  a  tender  ovary  often  gives  rise  to  acute 
pain  when  the  bowels  move,  from  the  pressure  on  it  in  de- 
fcecation ;  not  only  the  general  pressure  of  the  expulsive 
efforts  of  the  abdominal  walls,  but  the  pressure  of  the 
moving  ftecal  mass.  Consequently  the  action  of  the  bowels 
is  arrested,  and  then  constipation  follows,  with  a  load  in  the 
bowels  and  a  generally  worse  state  of  matters. 


122         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

Or  it  may  be  a  tender  uterus,  or  an  irritable  bladder,  or 
piles,  or  fissure.  Not  uncommonly  when  there  is  tender- 
ness of  the  lower  lobe  of  the  liver,  there  is  an  arrest  of 
action  in  the  ascending  colon,  with  an  accumulation 
making  things  worse.  (Obviously  here  the  bowels  must  be 
cleared,  and  be  kept  clear  of  load.)  This  is  a  form  of  con- 
stipation too  little  insisted  upon  in  medical  teaching. 

Irritable  Bowels. — With  some  persons  the  bowels  are  very 
irritable,  and  any  laxative,  however  mild,  gives  great  pain. 
As  a  comparatively  temporary  state  this  is  seen  commonly 
at  the  menopause.  It  is  found  with  some  delicate  persons 
at  all  ages,  but  increases  with  years,  speaking  broadly. 
With  such  persons  laxatives  warm  alike  with  carminatives 
and  in  temperature,  alone  are  tolerated.  (Hyoscyamus,  or 
other  of  the  solanacese,  may  be  indicated  to  restrain  the 
activity  of  the  '  circular  '  fibre  of  the  bowel.) 

The  old  writers  called  the  alimentary  canal  the  _2^ri7?ice 
mcG,  and  paid  great  respect  to  it  accordingly. 

The  anus  may  itch,  with  or  without  any  eruption,  when 
the  liver  is  inactive  :  while  a  coppery  blush  around  it  in  a 
baby  may  light  up  its  father's  early  history,  and,  with  it, 
much  family  trouble. 


\ 


CHAPTER  VII. 

THE   URINE. 

The  subject  of  the  urine  has  never  been  underrated  by 
students  of  medicine  :  whether  as  the  *  water-doctor'  of  a 
by-past  time ;  or  as  the  physiological  chemist  of  the  present 
day.  Views  have  changed  as  knowledge  increased.  ]!!iot 
more  than  a  generation  ago  the  deposits  in  the  urine  were 
carefully  examined ;  while  now  there  remains  only  the 
general  impression  that  phosphates  are  linked  with  ex- 
haustion of  the  nervous  system.  Instead  of  the  hopes  of 
that  day  being  realized,  the  very  views  themselves — that  in 
such  deposits  the  clue  to  many  morbid  states  would  be 
found — have  fallen  into  oblivion.  The  significance  of  tube- 
casts  remains  unchanged.  The  interest  now  seems  rather 
to  centre  round  albumen;  and  its  presence  or  absence  is 
assumed  to  be  the  evidence  on  which  the  opinion  is  to  be 
formed  as  to  whether  the  kidneys  are  diseased  or  not. 

[In  writing  on  this  matter  the  greatest  caution  has  to  be 
exercised.  The  examination-table  has  hard  and  fast  lines 
which  nature  does  not  always  rigidly  observe.  I  must,  then, 
insist  upon  the  student  who  pays  me  the  compliment  of 
reading  this  book,  fully  recognising  the  fact  that  this  work 
is  not  written  for  the  examination-table.  To  the  examiner 
he  must  carry  whcxt  is  taught  him  at  his  medical  school. 
Examiners  are  generally  teachers  :  they  have  some  general 
agreement  among  themselves  as  to  what  will  be  expected, 
and  what  must  be  tauoht.     The  medical  school  takes  the 


124  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

fees;  and  undertakes  to  fit  the  student  for  the  examination- 
table.  With  that  contract  I  do  not  wish  to  interfere  in  any- 
way !  Therefore  if  the  student  elects  to  carry  what  is 
written  here  to  the  examination-table,  he  clearly  under- 
stands that  he  does  it  at  his  own  risk  and  hazard.  If  he 
hesitates  about  the  grim  significance  of  the  presence  of 
albumen,  or  sugar  in  the  urine  before  an  examiner,  then 
the  blame  must  not  be  made  to  rest  on  me.  I  accept  no 
responsibility  in  connection  with  the  examination-table : 
while  perfectly  willing  to  accept  the  responsibility  con- 
nected with  practice  at  the  bedside.  It  is  perfectly  right 
and  proper  that  the  fundamental  ideas  of  the  student 
upon  the  subjects  of  albuminuria  and  glycosuria,  should  be 
that  they  indicate  serious  conditions.  The  first  tells  of 
kidney  disease,  a  very  grave  matter  ;  the  latter  of  diabetes, 
equally  serious.  This  aspect  should  constitute  the  basis  of 
his  views  on  these  matters.  But  upon  this  basis,  and  upon 
it  only,  a  superstructure  of  a  more  elaborate  character  may 
be  built  in  accordance  with  what  actual  practice  teaches. 
In  writing  on  '  Granular  Degeneration  of  the  Kidneys,' 
in  1839,  the  late  Sir  Robert  Christison  objected  to  the 
term  '  albuminuria '  as  indicating  disease  of  the  kidneys, 
under  which  heading  M.  Solon  had  written  his  treatise  on 
disease  of  the  kidneys,  saying  :  '  The  euphonious  elegance  of 
M.  Solon's  designation  will  not  altogether  atone  for  the 
philosophical  error  of  naming  a  disease  from  one  of  its 
symptoms.'  While  in  its  review  of  M.  Solon's  book,  the 
Lancet  raised  its  protest  against  the  term  '  as  a  substitute 
for  the  phrase  Bright's  disease '  ('  De  I'Albuminurie  ou 
Hydropsie  causee  par  Maladie  des  Reins,'  June  2ord,  183o). 
It  is  assumed  here  that  the  reader  has  passed  the  portals  of 
medicine,  has  left  the  examination-table  behind  him;  and 
that  he  is  beginning  to  grapple  manfully  with  the  com- 
plexities of  practice.] 

As  to  the  detection  of  albumen,  sugar,  or  hsemaglobuline, 
this  belongs  to  hospital  teaching.  It  is  with  the  significance 


THE  URINE.  125 

of  these  matters,  when  found,  this  discussion  is  concerned. 
Eecognition  is  assumed  to  have  been  made,  and  the  presence 
of  the  various  matters  ascertained  beyond  doubt,  before 
what  is  to  be  said  here  applies.  First  comes  the  bulk  of 
urine. 

Bulk  of  the  Urine. — This  is  the  first  matter  in  which  the 
young  practitioner  must  engage  in  the  consideration  of  the 
urine.  And  a  difficulty  meets  him  on  the  very  threshold  of 
his  inquiry.  Opinions  vary  as  to  the  normal  bulk  of  urine 
passed  in  twenty-four  hours.  This  depends  much  upon  the 
temperature  around  the  body.  When  the  skin  is  acting  freely, 
the  amount  is  smaller;  consequentl}^  the  bulk  of  urine  is 
greater  in  summer  than  in  winter.  The  quantity  of  fluid 
imbibed  affects  the  question  gravely.  Some  people,  too, 
most  undoubtedly  have  more  active  kidneys  than  others 
possess.  Remembering  all  this,  it  may  be  said  the  bulk  of 
urine  passed  in  the  twenty-four  hours  is  normally  about 
fifty  fluid  ounces,  or  two  pints  and  a  half. 

In  calculating  the  bulk  of  solids  passed  in  any  specimen 
of  urine,  the  daily  '  outflow '  must  be  the  basis  of  calcula- 
tion. But  the  outflow  has  a  significance  of  its  own,  quite 
independent  of  its  relations  to  the  '  output '  of  urine  solids, 
or  other  constituents. 

Traube  taught  the  great  matter  to  be  borne  in  mind  as 
regards  the  bulk  of  urine,  was  its  relation  to  the  blood-pres- 
sure in  the  arteries.  When  this  was  high,  the  bulk  of  urine 
was  great ;  when  the  blood-pressure  falls,  the  amount  of 
urine  drops  with  it.  In  the  slack  arteries  of  pyrexia,  as 
seen  in  the  specific  fevers,  the  bulk  of  urine  is  low.  In  the 
tense  artery  of  the  hypertrophied  left  ventricle  in  granular 
kidney  the  bulk  of  urine  is  high. 

The  larger  the  bulk  of  urine  the  lower  the  specific 
gravity ;  except  in  glycosuria.  That  is  a  broad  rule  to  be 
remembered.  As  regards  what  are  spoken  of  as  urine  solids, 
the  rule  holds  good  certainly.  The  converse,  too,  is  true;  a 
urine  of  small  bulk  is  usually  a  concentrated  urine,  highly 


126  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

charged  with  urine  solids.  Speaking  still  broadly  as  to  the 
question  of  *  output '  and  '  outflow,'  it  is  held  that  more  urine 
solids  are  excreted  with  a  urine  scanty  in  bulk,  but  dense ; 
than  with  a  dilute  urine  of  large  bulk,  but  low  specific 
gravity. 

Urine  pigment  is  distinct  from  urine  solids.  But  a  high- 
coloured  urine  is  a  dense  urine  as  regards  solids,  and  is  an 
odorous  urine.  A  pale  urine  is  a  dilute  urine  as  regards 
urine  solids :  although  in  glycosuria  the  urine  is  both  pale 
and  copious  ;  but  sugar  is  not  a  '  urine  solid.' 

The  change  in  the  bulk  of  urine  is  often  most  instructive. 
When  the  vasculo-cardiac  changes  of  '  the  granular  kidney,' 
or 'the  gouty  heart,' according  to  the  standpoint  of  view 
taken,  are  stealthily  progressing  with  sure  but  silent  step, 
the  bulk  of  urine  rises.  In  the  early  stage  of  '  chronic 
Bright's  disease/  as  a  third  person  might  choose  to  call  the 
complex  affection,  the  urine  is  copious  and  of  low  specific 
gravity.  When  in  time  the  hypertrophied  heart  undergoes 
mural  decay  from  fatty  degeneration,  and  the  vigour  of  the 
left  ventricles  relaxes  in  consequence,  the  bulk  of  urine  falls. 
Like  a  dissolving  view,  the  copious  pale  urine  of  the  high 
arterial  tension  passes  into  the  concentrated  scanty  urine  of 
cardiac  failure,  as  Sir  William  Jenner  has  pointed  out.  To 
put  the  question,  '  Do  you  pass  as  much  water  as  you  used 
to  do  ?'  and  to  receive  the  reply,  *  Oh,  no  ;  not  nearly  so 
much,'  is  to  throw  a  strong  light  upon  the  precise  position 
of  the  case  in  the  long  pathological  process.  It  is  entering 
upon  the  downward,  and  final  change.  Wlien  the  reply  is 
to  this  eff'ect  :  '  Yes ;  more,  I  think,'  then  the  case  is  at  an 
earlier  stage ;  on  the  ascent  to  the  summit  of  hypertrophy. 
An  increasing  bulk  of  urine  tells  that  the  case  is  at  the 
stage  of  waxing  hypertrophy ;  the  fall  in  bulk  tells  that 
the  hypertrophy  is  being  undermined  by  a  histolj^tic  pro- 
cess. In  dealing  with  old  and  elderly  persons,  this  question 
of  the  bulk  of  urine  is  one  of  cardinal  importance,  and  will 
repay  thought. 


THE  URINE.  127 

Then  *  polyuria '  is  found  after  an  hysterical  attack,  where 
there  has  been  a  tight  artery,  with  or  without  palpitation. 
It  is  found  with  diabetes  insipidus,  and  with  diabetes  melli- 
tus,  though  not  necessarily  with  glycosuria. 

Then  the  bulk  falls  in  febrile  conditions,  in  dropsy,  and 
in  cholera  (in  the  last  probably  from  spasm  of  the  renal 
vessels). 

Ischuria  renalis  is  suppression  of  urine.  It  may  be  found 
without  organic  kidney  change,  though  this  is  rare.  It  is 
sometimes  seen  in  that  curious  malady  hysteria.  If  the 
urine  is  suppressed  after  it  has  been  albuminous  or  bloody, 
then  thrombosis  of  the  renal  vein  may  be  suspected. 

Characters. — The  questions  of  colour  and  density  of  the 
urine  have  been  spoken  of  to  some  extent  in  reference  to  the 
bulk  of  the  urine.  It  varies  as  to  colour  in  health,  from 
'  limpid,'  as  after  hysteria  or  a  large  draught  of  fluid  con- 
taining alcohol,  to  'straw-coloured'  and  'brown  sherry,' 
when  concentrated  by  being  long  retained  in  the  bladder, 
with  a  freely  acting  skin.  The  pigments  of  the  urine  may 
be  normal,  or  the  consequence  of  decomposition  in  the  urine 
after  being  passed.  A  pale  urine^  after  it  has  stood  twenty- 
four  hours,  may  be  found  decidedly  pink.  Purpurine  is 
carried  down  with  a  lithatic  sediment,  as  the  deep  pink 
deposit  often  seen  aftev  a  cold,  or  in  organic  disease,  espe- 
cially in  the  liver.  Bile  is  found  in  the  urine  in  jaun- 
dice. The  urine  is  '  smoky  '  in  scarlatina  when  the  kidneys 
are  involved.  The  urine  may  be  '  bloody '  when  blood  is 
intimately  mixed  with  it  in  the  kidney.  But  the  urine  may 
resemble  blood  really  ;  not  merely  as  a  loose  expression  by 
a  careless  observer  (a  high-coloured  urine  is  constantly 
spoken  of  as  '  like  blood '  by  hospital  out-patients)  ;  but 
really  be  so  like  blood  as  only  to  be  distinguished  therefrom 
by  a  chemical  test.  Rhubarb  produces  such  a  hue  when  the 
urine  becomes  ammoniacal ;  and  such  a  urine  once  came 
under  my  notice  when  assistant  physician  at  the  West 
London  Hospital,  which  was  pronounced  by  everyone  to  be 


128         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

'  bloody,'  only  it  did  not  lose  its  colour  when  it  came  to  be 
boiled.  Ordinarily  rhubarb  only  gives  a  'deep  gamboge 
yellow  '  tint  to  the  urine.  Senna  gives  a  'brownish  shade;' 
loo-wood  a  '  reddish  tinge ;'  while  santonin  gives  an  '  orange 
red  '  with  alkaline  urine,  and  a  '  rich  golden  yellow  '  with  an 
acid  urine.  Creosote,  carbolic  acid,  or  tar  give  a  '  dark 
brown '  or  almost  black  urine.  This  last  is  a  suggestive 
urine  truly ;  while  the  rhubarb  red  is  very  deceptive. 
Chylous,  or  milky  urine,  has  a  significance  all  its  own. 

Then  the  smell  of  the  urine  varies.  The  urine  of  the 
herbaceous  animals  is  often  ammoniacal ;  a  change  produced 
in  human  urine  by  decomposition.  There  are  sundry  drugs, 
as  copaiba,  cubebs,  and  turpentine,  which  scent  the  urine,  as 
does  asparagus,  or  even  garlic.  Diabetic  urine  has  a  sweet 
fragrance  when  fresh,  passing  into  a  sour  odour  on  standing 
some  time.  The  urine  may  acquire  a  tainted  odour  in 
suppuration  of  the  urinary  tract. 

There  is  one  characteristic  of  urine  not,  to  my  knowledge, 
described  in  books,  and  that  is  an  offensive  smell  when 
passed.  Personally  I  have  found  it  with  pasty-faced, 
elderly  women,  with  pale  stools  and  evidences  of  liver- 
derangement.  It  seems  allied  to  skatol  or  indol  in  its 
character,  and  is  intolerable  even  to  the  patient  herself. 

Sediments. — These  consist  of  the  urine  solids — tube-casts, 
epithelial  scales,  mucus,  pus,  or  blood  (when  coming  from 
low  down  in  the  urinary  passages,  so  as  not  to  be  thoroughly 
commixed  with  the  renal  secretion). 

Mucus  and  pus  are  suggestive  of  cystitis ;  and  pus  in  the 
urine  often  irritates  the  urinary  passages  very  markedly. 
They  may  indicate  urethritis,  or  be  vaginal  in  women. 
Strange  discoveries  of  vaginal  epithelium  in  the  urine  of 
bachelors,  and  of  spermatozoa  in  female  urine,  have  been 
made. 

Tube-casts  are  suggestive  of  acute  nephritis,  scarlatinal  or 
other ;  or  of  chronic  conditions.  They  vary  considerably  in 
appearance  and  significance ;  but  their  discussion  lies  rather 


THE  URINE.  129 

with    the  'anatomical'  than  the  'physiological'  factor  in 
diagnosis. 

k  phosphatic  sediment  was  once  the  object  of  very  minute 
scrutiny.  It  was  held  to  be  linked  with  nervous  irritability 
and  exhaustion,  and  those  '  in  whom  the  constitution  may 
be  considered  as  giving  way,  or,  to  use  a  common  expres- 
sion, breaking  up.' — Prout.  Mixed  phosphates,  too,  are 
found  with  '  injuries  to  the  back,  by  concussions,  blows,  or 
accidents,  particularly  if  other  causes  of  a  predisposing  or 
exciting  nature  favour  the  operation  of  such  accidents.'  A 
fall  from  a  horse  was  a  frequent  cause  of  such  injury* 
Prout  quotes  Brodie  :  '  The  phenomenon  seems  to  occur  in 
other  animals  as  well  as  man.  Thus  I  have  frequently 
observed  jaded  and  worn-out  horses  pass  great  quantities  of 
lime  in  their  urine ;  the  same  also  takes  place  occasionally 
in  dogs,  particularly  of  the  sporting  kinds.'  But  phos- 
phates seem  to  have  fallen  from  their  high  estate  in  medical 
opinion,  for  Wm.  Roberts  says :  '  There  is  not  the  least 
reason  to  believe  that  there  is  any  constitutional  state 
specially  characterized  by  an  excessive  excretion  of  phos- 
phates ;  the  phosphatic  diathesis  of  Prout  is  simply  ammo- 
niacal  urine.'  While  of  '  ammoniacal  urine  '  he  says  it  '  is 
only  in  the  rarest  instances,  and  in  the  gravest  circum- 
stances, secreted  ammoniacal  by  the  kidneys,  but  usually 
becomes  so  by  an  after-change  occurring  in  the  lower  urinary 
passages,  or  after  it  has  been  voided.' 

Oxalate  deposits  were  also  once  minutely  examined,  and 
an  oxalic  acid  diathesis  was  held  by  Prout  and  Golding 
Bird.  Here  there  is  great  nervous  irritability  with  de- 
pression and  incapacity  to  work,  either  mentally  or  bodily  ; 
while  the  sexual  power  is  deficient  or  even  absent.  Roberts 
disposes  of  the  matter  thus  :  '  I  am  strongly  convinced  that 
oxaluria  arises  from  a  variety  of  conditions — many  of  them 
not  accompanied  by  appreciable  departures  from  health 
— in  which  the  assimilation  of  food  or  the  disintegration  of 
the  tissues  goes  on  imperfectly,  and  that  it  is  impossible  to 

9 


130         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

assign  any  constant  train  of  sj'mptoms  as  the  cause  or  con- 
sequence of  oxaluria.  At  the  most,  oxaluria  is  only  one  of 
a  long  list  of  symptoms,  and  one  of  the  least  significant.' 
Bence  Jones  held  oxalic  acid  to  tease  the  brain  very  much; 
and  Prof,  Laycock  held  a  bad  champagne  (made  with 
rhubarb)  an  excellent  test  in  a  case  of  suppressed  gout. 
Gouty  persons  are  susceptible  to  oxalates,  beyond  doubt, 
and  should  avoid  sorrel,  rhubarb,  and  tomatoes  ;  some  even 
cannot  take  asparagus  without  suffering  for  it ;  and  a  small 
number  are  upset  by  broad  beans.  Especially  is  the  efifecfc 
marked  where  there  is  a  sensitive  urethra;  and  a  knowledge 
of  this  enables  one  frequently  to  tell  a  gouty  patient  he  has 
had  rhubarb,  or  tomatoes,  or  a  bad  champagne — a  matter 
which  impresses  him  considerably. 

Urea  never  spontaneously  becomes  a  sediment  in  the 
urine,  being  the  form  of  urine-excrement  essentially  belong- 
ing to  a  '  fluid  '  urine ;  while  uric  acid  is  the  constituent, 
]jar  excellence,  of  a  '  solid '  urine. — M.  Foster.  But  lithates 
constantly  form  a  sediment  if  the  urine  is  chilled  below  the 
deposit-temperature.  Uric  acid  is  thrown  down  as  urate  of 
soda,  urate  of  ammonia,  and  free  uric  acid.  The  clinical 
circumstances  under  which  tliese  three  forms  are  deposited 
vary ;  but  'a  urine  which  throws  down  urates  will  begin  to 
deposit  free  uric  acid  a  few  hours  after.' — W.  Roberts.  The 
highly  soluble  urate  of  potash  does  not  deposit. 

These  lithates,  or  urates,  are  found  under  various  circum- 
stances. Their  colour  is  not  without  significance,  and  the 
pink  urate  of  a  cold  is  well  known.  Sometimes  it  creates 
great  and  unnecessary  alarm.  '  A  pale  urate  is  the  urate  of 
indigestion,  thrown  down  a  few  hours  after  a  meal ;  while  a 
higher-coloured  urate  belongs  to  organic  disease,  and  is  of 
bad  omen  in  many  cases.  A  urate  is  formed  by  the  liver 
from  the  albuminous  matters  carried  to  it  by  the  portal 
vein  in  cases  of  mal-assimilation.  It  may  be  a  pale  urate, 
or  it  may  be  '  lateritious,'  '  fawn-coloured,'  '  brick-dust,'  or 
*  orange,'  or  '  pink ;'  sometimes  a  very  deep  pink  indeed. 


i 


THE  URINE.  131 

especially  in  old  gouty  subjects.  Consequently  the  colour 
of  the  lithatic  deposit  is  not  unimportant.  I  wish  it  were 
possible  to  describe  the  significance  of  the  colour  of  lithates 
in  a  satisfactory  manner ;  but  it  is  not  so,  and  the  reader 
must  still  think  out  their  significance  in  each  case  for  him- 
self; it  is  not  possible,  as  yet,  to  do  his  thinking  for  him 
on  this  topic.  Having  given  much  thought  to  it,  and  be- 
lie viug  it  to  be  important,  the  subject  will  be  put  before 
the  reader  as  well  as  may  be — at  least,  his  attention  shall 
be  drawn  to   it. 

Older  writers,  as  Prout,  have  studied  this  question  ;  but 
it  may  be  well  to  give  a  recent  authority  first.  William 
Roberts  says  : — '  The  frequent  or  constant  occurrence  of  a 
brownish  or  red  urate  deposit,  without  or  with  only  a  feeble 
degree  of  pyrexia,  is  a  circumstance  to  awaken  suspicions  of 
some  serious  organic  disease;  but  the  indication  is  more 
general  than  special.  Organic  disease  of  the  lungs,  hearts 
spleen,  or  any  other  part,  attended  with  emaciation  and 
waste  of  the  tissues,  is  usually  accompanied  with  abundant 
deep-coloured  urine  deposit.'  Prout  wrote  :  'During  feverish 
or  other  derangements,  in  which  the  functions  of  the  hepatic 
system  are  particularly  involved,  the  lithate  of  ammonia  is 
not  only  supposed  to  be  derived  from  the  imperfectly 
assimilated  chyle,  and  the  deteriorated  albuminous  prin- 
ciples of  the  blood,  but  also  from  the  deranged  secondary 
assimilation  of  the  albuminous  textures  of  the  body.'  In 
organic  disease  of  the  liver,  quantities  of  uric  acid  may  be 
found  in  the  urine  (Murchison)  ;  while  tyrosin  is  found  in 
the  urine  in  acute  yellow  atrophy  of  the  liver  in  notable 
quantities.  These  retrograde  products  of  albuminoids 
hail  from  the  liver,  whether  that  viscus  is  the  subject  of 
disease  itself  as  cancer,  or  is  functionally  perverted  by 
general  systemic  disturbance;  perhaps  set  up  by  disease 
elsewhere. 

Then  as  to  the  pale  urates  of  indigestion,  they  have  long 
been  recognised.     Roberts  says  of  them  :  '  Functional  de- 

9—2 


132         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

rangeraents  of  the  digestive  organs  are  also  generally 
accompanied  by  pale  urate  deposits  in  the  urine.' 

The  subject  has  attracted  my  attention,  and  the  summary 
is  as  follows : — '  Urates  themselves  are  colourless,  but  the 
amount  of  pigment  they  carry  with  them  varies  with  the 
different  circumstances  under  which  they  are  formed;  hence 
the  significance  of  their  colour.  The  paler  the  urate  deposit, 
the  more  urate  of  soda  is  present ;  the  deeper-coloured,  the 
larger  the  proportion  of  urate  of  ammonia.  White  deposits 
of  urate  of  soda  are  associated  with  indigestion;  deep  urate 
deposits  with  pyrexia,  organic  disease,  or  the  concentrated 
urine  of  venous  fulness,  as  in  cardiac  failure '  ('  Indigestion, 
Biliousness,  and  Gout  in  its  Protean  Aspects,'  Part  II.  p.  277). 

Free  uric  acid  in  rhombs  is  found  under  circumstances  of 
its  own.  It  is  common  in  strumous  children,  and  the  acid 
irritates  the  urethra  no  little  in  many  cases.  Sometimes 
the  irritation  of  the  bladder  leads  to  wetting  the  bed  at 
night.  Uric  acid  calculus  may  readily  be  formed.  The 
*  cayenne  grains  '  of  uric  acid  are  as  marked  in  such  children 
as  they  are  in  gouty  adults.  The  union  of  gout  with  struma 
seems  the  combination  favourable  to  free  uric  acid.  The 
appearance  of  lithic  sediments  is  not  to  be  feared ;  rather  is 
it  hailed  with  delight  by  the  patient.  '  It  is  not  when  you 
see  them,  but  when  you  don't  see  them,  that  you  are  to  be 
anxious,'  said  a  shrewd  old  doctor  to  me  in  early  days. 
This  is  worth  bearing  in  mind  as  to  their  significance.  'Who- 
ever has  attended  much  to  urinary  diseases  must  have 
remarked  that  many  individuals  subject  to  derangements 
of  the  general  health  seldom  feel  so  well  with  respect  to 
their  health,  as  when  lithic  acid  deposits  take  place  in  the 
urine.' — Prout. 

Lithic  acid  is  found  in  the  gouty;  also  with  those  who 
have  resided  long  in  hot  climates,  especially  those  who 
have  had  hepatic  trouble,  when  it  is  present  most  in  the 
winter  months  ;  and  again  in  '  middle-aged  females  who 
laboured  (or  are   about   to   labour)    under  chronic  uterine 


THE  URINE.  133 

disorder;  especially  of  the  malignant  kind.  Thus  lithic 
acid  deposition  has  a  varied  significance.'  Prout  continues, 
'  When  the  deposition  of  lithic  acid  appears  about  the 
middle  period  of  life,  for  the  first  time,  in  broken-down 
constitutions  and  unhealthy  subjects,  so  far  from  bringing 
relief  or  indicating  a  favourable  result,  as  in  the  first  class 
of  aff'ections  above  stated,  such  deposition  is  not  unfre- 
quently  the  sure  forerunner  of  a  general  break-up  of  the 
system,  and  of  speedy  dissolution,  of  which  I  have  seen 
a  great  many  instances.'  He  also  observed  the  relation 
of  lithic  acid  to  diabetes,  'Such  a  combination  is  by  no 
means  unusual  in  corpulent  middle-aged  individuals  of  a 
gouty  strumous  habit,  and  is  always  to  be  viewed  with 
some  degree  of  anxiety.' 

The  subject  of  the  lithatic  deposits  in  the  urine  is  fraught 
with  interest  on  every  side.  The  subject,  however,  is  only 
attractive  to  reflecting  persons. 

Urea. — This  is  the  normal  form  of  the  retrograde  meta- 
morphosis of  nitrogenized  matter  in  warm-blooded  animals 
with  a  fluid  urine ;  no  matter  whether  the  debris  of  tissue, 
or  the  luxus  consumption  of  albuminoids  beyond  the  tissue- 
needs.  In  some  hepatic  conditions  almost  the  whole  of 
the  albuminoids  are  transformed  into  urea,  the  Baruria, 
or  Azoturia  of  various  writers.  Urea  is  often  found  in 
large  quantities  in  diabetic  persons,  possibly  often  the 
result  of  the  meat-dietary  followed  out  to  excess;  some- 
times perhaps  the  result  of  an  exciting  cause  common 
to  both,  as  mental  anxiety,  disturbing  the  liver  alike  in 
its  glycogenic  function,  and  its  second  function,  i.e..  the 
metabolism  of  albuminoids. 

In  febrile  conditions  there  is  a  great  quantity  of  urea 
formed,  sometimes  a  very  large  quantity,  from  the  tissue- 
disintegration  caused  by  a  high  temperature. 

The  amount  of  urea  in  the  urine  is  small  in  chronic 
Bright's  disease,  whether  gouty  or  albuminuric. 

Albuminuria. — The  presence  or  absence  of  albumen  in  the 


134         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

urine  is  now  almost  universally  assumed  to  be  the  test  of 
the  presence  or  absence  of  Bright's  disease.  There  is  a 
delightful  simplicity  in  thus  settling  a  matter  which  really 
presents  the  greatest  difficulties  in  many  cases.  The  whole 
question  is  too  exclusively  made  to  turn  on  the  accuracy 
of  the  observation,  and  the  method  employed.  The  student 
is  taught  the  different  tests,  the  sources  of  fallacy  of  each, 
usque  ad  nauseam.  Allow  me  to  assure  him,  as  emphati- 
cally as  it  is  in  my  power  to  do,  that  the  question  of  the 
detection  of  albumen  in  the  urine  is  easy  by  comparison 
with  the  difficulty  of  estimating  its  importance  when 
it  is  found.  Shortly  after  Bright  had  familiarized  the 
medical  mind  with  the  importance  of  examining  the  urine, 
and  shown  the  relation  albuminuria  holds  to  the  diseases 
which  bear  his  name,  when  albumen  was  found  in  the 
urine  it  was  assumed  to  be  the  herald  of  coming  dissolution. 
Death  was  soon  to  follow.  Old  practitioners  have  told  me 
how  the  detection  of  albumen  in  the  urine  was  followed 
by  the  fear  of  death  in  medical  men  themselves  at  that 
time.  On  its  discovery,  by  any  accident,  they  took  to  bed, 
settled  their  worldly  affiiirs,  and  prepared  for  the  final 
change.  But  finding  after  a  time  that  they  were  not 
perceptibly  worse,  they  began  to  get  up  and  go  about ;  and 
feeling  no  evil  effects  therefrom,  resumed  work ;  regarding 
their  scare  with  mingled  feelings.  They  had  trodden  '  the 
valley  of  the  shadow  of  death  '  in  anticipation.  As  years 
rolled  on  they  told  the  tale  of  the  past  as  an  instance  of 
the  fallacies  of  medicine.  No  doubt  when  the  urine  is  seen 
to  undergo  the  significant  opacity  as  the  boiling  point  is 
reached,  the  apprehensions  are  naturally  aroused ;  and  a 
timid  man  may  feel  a  dread  creep  over  him  as  if  the  rustle 
of  the  wings  of  the  King  of  Terrors  was  already  audible. 
The  feeling  is  a  natural  one,  and  does  not  indicate 
cowardice.  What  I  wish  to  insist  upon  is — taken  alone, 
the  presence  of  albuminuria  is  of  doubtful  significance. 
It  is  certainly  well  to  start  off  with  the  assumption  that 


THE  URINE.  1 35 

it  is  of  grave  significance  ;  the  debatable  point  is  this :  Is 
it  well  to  rest  there  ?  That  is  the  question.  On  the  other 
hand.  Dr.  Mahomed  has  written  a  thesis,  to  my  mind  of 
very  high  value,  on  the  topic :  '  Chronic  Bright's  Disease 
without  Albuminuria.' 

It  is  a  well-recognised  fact  that  in  cirrhosis  of  the  kidney, 
the  granular,  or  gouty  kidney,  albumen  is  only  present 
fitfully ;  and  is  often  altogether  absent  for  long  intervals. 
Albuminuria  then  is  but  one,  albeit  a  very  important  one, 
of  the  evidences  of  renal  disease.  Something  more  is 
required  than  the  behaviour  of  the  contents  of  a  test-tube 
to  settle  the  question  of  renal  changes. 

What  I  wish  the  reader  fully  and  rationally  to  realize  is  : 

(1)  There  may  be  albuminuria  without  renal  disease  ;  and 

(2)  There  may  be  renal  disease  without  albuminuria. 
And  if  the  examination-table  does  not  insist  upon  the 

recognition  of  these  two  great  clinical  facts,  actual  practice, 
he  will  find,  does  insist  upon  it.  Admitting  to  the  full  the 
value  of  the  discovery  so  linked  with  the  name  of  Bright, 
it  is  equally  necessary  to  urge  caution  and  judgment  as  to 
the  interpretation  to  be  put  upon  albuminuria. 

The  discovery  of  albuminuria  dates  back  far  beyond  the 
time  of  Bright.  In  June,  1811,  Dr.  Wells  'considered  the 
subject  of  serous  urine  in  a  truly  elaborate  manner,'  in  a 
paper  he  read  before  the  Society  for  the  Improvement  of 
Medical  and  Chirurgical  Knowledge.  While  Bright's 
famous  Gulstonian  Lectures  were  delivered  before  the 
Royal  College  of  Physicians  in  1833,  from  whence  date 
our  modern  opinions  about  albuminuria. 

In  the  'Library  of  Medicine '  Sir  Robert  Christison  wrote  of 
'  Granular  Disease  of  the  Kidney '  as  follows  : — '  Albumen 
is  commonly  present;'  and  'It  is  sometimes,  however, 
absent  altogether  for  a  time,  especially  when  the  urine  is 
discharged  more  freely  than  natural.'  Then  he  makes  two 
very  practical  remarks,  well  worth  quotation,  as  furnishing 
material  for  reflective  thought.     '  Its  proportion  generally 


136         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

increases  wlien  incidental  inflammatory  action  is  excited  ;  and 
in  that  case  the  urine  puts  on  the  characters  of  the  acute 
form,  except  that  its  density  remains  low;'  that  is  one. 
Then  'It  is  a  complete  mistake  to  hold  with  some  late 
authors  that  the  albumen  increases  in  proportion  as  the 
disease  advances  ;'  that  is  the  second.  The  reader  will  see 
from  this  it  is  not  correct  to  assume  that  renal  disease  is 
not  present  because  there  is  not  albumen  in  the  urine. 
That  is  a  cardinal  fact  to  remember.  Dr.  Prout,  an 
authority  on  whom  equal  reliance  can  be  placed,  made  this 
division : 

Species  a.  Serous  UHne :  the  Jcidney  in  a  state  f  Var.  1.  Quiescent. 

of  health.  \  Var.  2.  Inflamed. 

Species  h.  Serous  Urine :  the  kidney  in  a  state  f  Var.  1.  Quiescent. 

of  degeneration.  \  Var.  2.  Inflamed. 

In  speaking  of  the  difficulties  surrounding  the  subject,  he 
writes  trenchantly  : — '  With  respect  to  illogical  reasoners, 
it  may  be  observed  that  there  are  some  minds  so  singularly 
constituted,  that  they  appear  to  be  unable  to  comprehend 
the  distinction  between  a  general  and  a  universal  law  ;  i.e., 
between  a  general  law,  founded  on  experience^  and  there- 
fore admitting  of  exceptions,  and  a  universal  law,  founded 
on  reason  or  necessity,  and  consequently  admitting  of  no 
exceptions.  Of  this  remark  the  subject  of  serous  urine 
affords  a  striking  illustration.  Forgetting  that  all  they 
know  on  the  subject  of  serous  urine  is  founded  solely  on 
experience,  and  assuming  as  the  basis  of  their  argument 
the  illogical  grounds  that  serous  urine  always  denotes 
disease  of  the  kidneys,  some  have  deduced  from  the 
admitted  exceptions  to  the  law  the  opposite,  and  equally 
illogical  conclusion,  that  serous  urine  does  not  indicate 
disease  of  the  kidneys.  To  point  out  instances  of  such 
illogical  reasoning  would  be  invidious;  while  the  attempt 
to  refute  it  would  be  waste  of  time.'  Certainly,  Dr.  Prout, 
it  might  be  waste  of  time,  but  the  illogical  reasoner   on 


THE  URINE.  137 

albuminuria  exists  still ;  perhaps  is  even  more  common 
than  he  was !  He  held  that  when  the  urine  was  of  high 
specific  gravity,  of  deep  colour,  of  moderate  or  rather 
diminished  quantity,  when  the  lithate  of  ammonia  was 
present,  the  prospect  was  good  in  chronic  degeneration,  as 
compared  to  the  opposite  condition.  Here  the  bulk  of 
urine  is  large,  it  is  pale-coloured,  and  of  low  specific  gravity; 
sometimes  the  bulk  is  large,  but  when  to  the  above  the 
bulk  is  small,  then  an  advanced  condition  of  the  disease  is 
present.  Of  course  when  any  intercurrent  congestion  or 
inflammation  be  present  in  chronic  renal  disease,  whether 
there  be  albuminuria  ordinarily  present  or  not,  at  these 
periods  of  acute  action  the  albuminuria  is  conspicuous. 
The  surroundings  of  albuminuria,  even  other  matters 
connected  with  the  urine  itself,  were  estimated  by  Prout 
in  trying  to  realize  the  significance  of  albuminuria. 

It  may  now  be  well  to  see  the  position  of  albuminuria 
by  the  light  of  more  recent  opinion.  William  Roberts  says : 
— 'Slight  and  temporary  albuminuria  appears  to  occur 
occasionally  from  very  slight  disorders.  Beneke,  when 
suflfering  from  dyspepsia,  noticed  albumen  in  his  own  urine 
four  times  in  as  many  weeks.  Similar  observations  have 
been  made  by  others  (Parkes).  Setting  aside  these 
unimportant  exceptions,  albuminuria  must  always  be  looked 
on  as  a  grave  symptom  of  disease ;  and  when  discovered 
it  becomes  an  anxious  question  to  the  practitioner  :  What 
signification  has  it  ?' 

He  continues : — '  When  albumen  is  found  in  the  urine, 
the  important  point  to  decide  is  whether  it  indicates  the 
existence  of  organic  disease  of  the  kidneys  or  not.  This 
question  in  any  individual  case  must  be  considered  chiefly 
in  connection  with  the  three  following  points,  jointly, 
namely : — 

'  1.  The  temporary  or  persistent  duration  of  the  albumi- 
nuria. 


138  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

'2.  The  quantity  of  the  albumen;  and  the  occurrence  and 
character  of  a  deposit  of  renal  derivatives. 

'  3.  The  presence  or  absence  of  any  disease  outside  the 
kidney  wliich  will  account  for  the  albuminuria,' 

In  connection  M'ith  this  last  he  says  : — '  When  the  urine 
is  found  permanently  albuminous,  and  there  exists  neither 
P3U'exia  nor  thoracic  disease,  or  other  recognisable  condition 
"which  can  account  for  the  albumen,  the  inference  is  almost 
irresistible  that  there  exists  a  primary  organic  disease  of 
the  kidneys.' 

The  most  recent  and  solid  utterance  on  this  subject  is 
that  on  Albuminuria  in  Quain^s  Dictionary,  by  Dr.  T. 
Lauder  Brunton,  F.R.S.,  whose  opinion  is  entitled  to  our 
highest  respect.  He  writes  : — '  In  order  to  distinguish  more 
clearly  between  the  different  kinds  of  albuminuria  we  may 
divide'  them  into — 1st,  tvue  albuminuria,  in  which  serum- 
albumin  appears  in  the  urine  ;  2nd,  false  albuminuria, 
in  which  some  other  albuminous  body,  but  not  serum- 
albumin,  is  present.  In  true  albuminuria  there  is  always 
some  change  either  in  the  circulation  through  the  kidney, 
or  in  the  structure  of  the  kidney  itself.  In  falm  albumi- 
nuria the  albuminous  body  passes  out  through  the  kidney, 
without  there  being  any  alteration  either  in  circulation  or 
structure.  The  chief  albuminous  bodies  occurring  in  false. 
abuminuria  are  haemoglobin,  egg-albumin,  and  Bence  Jones' 
albumin.'  Now,  if  the  young  practitioner  cannot  trust 
himself  to  distinguish  betwixt  *  serum-albumin '  and  other 
forms  of  albumen — and  no  one  will  hold  him  cheap  for  such 
diffidence — the  best  thing  for  him  to  do  is  to  send  the 
patient  to  some  one  who  can  make  the  distinction ;  or  at 
least,  whom  he  believes  can  do  so. 

Indeed,  in  all  cases  of  albuminuria  in  important  lives,  at 
least,  the  young  practitioner  will  act  wisely  and  prudently, 
in  his  own  interests  as  well  as  the  patient's,  in  consulting 
some  older  person.  But  not  as  a  means  of  relieving 
himself  from   the  necessity  for   close  study  of  the  case ; 


THE  URINE.  139 

certainly  not  that !  But  to  share  the  responsibility  which 
attaches  to  him  under  these  circumstances.* 

In  cases  where  the  finances  of  the  patient  will  not  admit 
of  this,  act  warily.  If  a  club  patient  presents  himself,  com- 
plaining of  feeling  ill,  and  no  ostensible  cause  be  apparent, 
then  it  is  well  to  examine  the  urine ;  and,  if  either  albumen 
or  sugar  be  found,  to  keep  a  watchful  e3''e  on  him.  Take 
the  albuminuria  in  connection  with  its  surroundings.  On 
the  other  hand,  when  a  person  feeling  well  is  found  to  have 
albuminuria,  do  not  lose  your  head  ;  and  frighten  first  your- 
self, and  then  your  patient,  and  that  patient's  friends  !  If 
you  err,  they  may  not  make  that  allowance  for  the  error 
that  acquaintance  with  the  difficulties  of  the  subject  would 
cause  them  to  make  :  they  only  know  you  erred,  as  time 
goes  on  and  does  not  verify  your  opinion. 

Finally,  do  not  commit  the  common  error — for  error  it 
undoubtedly  is — of  confounding  albuminuria  with  Bright's 
disease.  That  this  is  quite  commonly  done  is  no  excuse  for 
so  palpable  an  error.  The  diagnosis  of  chronic  renal  disease 
does  not  turn  on  the  behaviour  of  the  contents  of  a  test- 
tube,  taken  alone.     '  Taken  alone,'  please  note,  reader ! 

Glycosuria. — This  term  is  to  be  preferred  to  that  of 
'diabetes^  for  diagnostic  purposes;  because  diabetes  is  a 
grave  disease,  of  which  glycosuria  is  but  a  symptom — albeit 
a  very  important  symptom.  '  Glycosuria '  is  no  more 
'  diabetes,'  than  '  albuminuria '  is  '  Bright's  disease  ' ! 

In  order  to  give  the  reader  a  clear  impression  of  the 
clinical  aspect  of  diabetes,  the  subject  will  be  treated  some- 
what historically.     Prout  (1849)  put  the  position  thus: — 

*  And  here  let  me  give  my  reader  a  word  of  caution,  as  I  might  to 
a  younger  brother  ;  indeed,  he  is  '  my  professional  brother ' :  do  not 
look  merely  at  the  present;  all  may  be  satisfied  and  confident  in  him 
at  the  time.  But  if  the  case  goes  wrong,  some  very  unpleasant  and 
unfair  things  may  be  said— and  often  are  said.  And  a  man  has  to 
guard  his  own  reputation,  as  well  as  do  his  honest  best  for  his 
patient. 


I40        PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

'  The  general  jprognosis  in  diabetes  must  be  considered  as 
unfavourable.  Among  the  favourable  symptoms  in  this 
affection  may  be  enumerated,  a  moderate  flow  of  urine  of  a 
specific  gravity  not  higher  than  1035  ;  the  appearance  in 
the  urine  of  lithic  acid  either  in  its  amorphous  or  crystal- 
lized form ;  the  recent  appearance  of  the  disease,  and  the 
absence  of  thirst ;  the  retention  or  gain  of  flesh  and  strength ; 
and,  more  than  all,  immunity  from  organic  disease — more 
especially  from  organic  disease  of  the  lungs.  On  the  con- 
trary, when  the  flow  of  urine  is  permanently  excessive,  and 
of  high  specific  gravity;  or  when  the  secretion  is  pale- 
coloured,  opalescent,  and  serous  ;  when  the  thirst,  emacia- 
tion, and  debility  are  extreme ;  or  when  organic  disease, 
particularly  of  the  lungs,  is  present,  the  chance  of  recovery 
is  much  diminished.  But  when,  as  is  too  frequently  the 
case,  several  or  all  of  these  unfavourable  symptoms  co-exist, 
the  chance  of  recovery  is  not  only  diminished,  but  absolutely 
Jiopeless.'  Here  Prout  puts  the  whole  matter  concisely  and 
clearly. 

Niemeyer  recognises  a  difference  in  cases,  saying  :  'There 
is  no  doubt  that  patients  in  comfortable  circumstances,  and 
who  possess  the  means  of  taking  good  care  of  themselves, 
hold  out  against  diabetes  much  longer  than  those  who  are 
obHged  to  take  refuge  in  hospitals.  A  complete  and  per- 
manent recovery  from  diabetes  (if  it  ever  occur  at  all)  is 
extremely  rare,  although  plenty  of  cases  have  been  recorded 
in  which  a  pause  in  the  symptoms,  of  longer  or  shorter 
duration,  has  been  observed.'  That  even  severe  attacks  of 
diabetes — that  is,  of  glj^cosuria  accompanied  by  other 
symptoms — are  recovered  from,  is  not  so  extremely  rare  in 
this  country.  Several  have  come  under  my  own  notice 
from  time  to  time. 

Glycosuria,  beyond  the  grave  and  fatal  disease  of  'diabetes 
mellitus,'  which  runs  a  course  of  from  one  to  three  years, 
it  has  been  calculated,  may  be  found  with  two  other  sets  of 
associations  in  my  experience.    They  are  :  (!)  Acute  attacks 


THE  URINE.  141 

of  sharp  diabetes,  passing  away  in  a  little  time ;  (2)  a 
chronic  condition  which  goes  on  without  working  any  con- 
stitutional ruin,  usually  occurring  in  well-nourished  persons. 

(1)  These  attacks  may  be  fatal,  but  not  necessarily  so, 
much  depending  upon  the  treatment  adopted.  Certainly, 
in  all  cases  it  is  well  to  give  a  guarded  opinion,  representing 
faithfully  your  impressions.  But  every  now  and  again  you 
will  be  agreeably  surprised  to  find  that  your  grave  prognosis 
is  not  verified.  Since  commencing  this  section,  an  old  lady 
has  been  in  my  house,  hale  and  strong  for  her  years,  who 
two  years  ago  was  regarded  as  hopelessly  ill  with  diabetes 
by  three  excellent  provincial  physicians  met  in  consulta- 
tion. In  an  address  to  the  Clinical  Society,  at  its  opening 
for  the  session  1882-83,  Dr.  Andrew  Clark,  referring  to  a 
state  of  temporary  albuminuria  occurring  under  the  strain 
of  prolonged  competitive  examinations,  said  :  '  Of  the  young 
men  competing  for  places  in  the  Indian  Civil  Service 
Examination,  I  have  ascertained  by  repeated  personal 
examinations  that  more  than  one-tenth  become  albuminuric' 
He  continued,  '  I  will  conclude  with  merely  mentioning 
the  glycosuric  storms  which,  without  sensibly  damaging  the 
body  or  materially  impairing  health,  come  and  go  through 
a  lengthened  life.'  It  seems  highly  probable  that  acute 
attacks  of  what  ai^e  really  *  glycosuric  storms  '  are  mistaken 
at  times  for  diabetes. 

(2)  Many  medical  men  have  told  me  of  the  horror  with 
which  they  recognised  the  fact  of  there  being  sugar  present 
in  their  urine.  Testing  a  doubtful  specimen,  to  be  sure 
about  the  test,  they  proceeded  to  examine  their  own  urine, 
believing  themselves  to  be  in  perfect  health,  and  found  it 
to  contain  more  sugar  than  the  doubtful  specimen.  After  a 
while  the  sugar  disappeared,  to  their  great  delight  and 
relief.  (In  some  cases  a  rigid  non-saccharine  dietary  was 
adopted  with  such  severe  results,  that  it  had  to  be  modified 
considerably.) 

Then   there  are  persons   who   are   well   nourished   who 


142         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

experience  a  '  glycosuric  storm,'  from  some  cause  of  mental 
character ;  and  who  find  more  or  less  sugar  in  their  water 
ever  afterwards.  Speaking  to  Sir  William  Jenner  some 
time  ago  of  these  cases,  he  said  he  had  a  number  of  glyco- 
suric cases  under  observation,  who  did  not  seem  to  be  much 
the  worse  therefor.  My  comment  was,  '  Stout,  well- 
nourished  persons  do  not  die  of  wasting  maladies;'  with 
which  he  agreed.  Glycosuria  when  causally  linked  with 
mental  shock,  strain,  or  worry,  may  be  a  mere  '  glycosuric 
storm,'  or  may  be  the  '  classical  diabetes,'  as  W.  Roberts 
terms  it.  (Much  depends  on  what  is  done.  Relief  from 
the  cause  of  the  diabetes  will  commonly  bring  with  it 
great  amelioration,  if  not  cure.  While  if  the  patient  go  on 
in  his  way  death  is  before  him.)  One  case  is  well  known 
to  me  where  a  well-nourished  man  is  well  ordinarily,  but 
who  gets  a  '  glycosuric  storm '  whenever  worried  with 
business.  Many  stout  men  are  glycosuric  without  apparent 
injury  to  their  health.  Sometimes  the  urine  varies,  being 
copious,  opalescent,  and  laden  with  sugar;  while  at  other 
times  it  is  amber-coloured,  and  deposits  of  lithic  acid  are 
found,  not  copious  nor  of  high  specific  gravity.  Here  the 
condition  is  found  to  vary  with  the  demand  upon  the 
brain.  In  fact,  betwixt  these  last,  where  the  glycosuria  may 
be  regarded  as  a  '  waste-pipe '  affair^  the  running  ofi"  of  the 
luxus  consumption  of  sugar  ;  the  patient  subject  to  'glyco- 
suric storms ;'  and  the  '  classical  diabetes,'  there  are  a 
variety  of  grades  not  yet  worked  out :  and  which  con- 
stitute in  practice  great  stumbling-blocks. 

William  Roberts  says  : — '  The  progress  of  diabetes  is 
usually  equable  and  continuous ;  but  cases  are  met  with, 
not  very  unfrequently,  in  which  the  symptoms  intermit — 
the  saccharine  state  of  the  urine  ceasing  and  recurring  at 
intervals.  Dr.  Bence  Jones  has  published  an  account  of 
several  such  cases  in  old  persons ;  and  I  have  encountered 
similar  ones  in  my  own  practice.'  Of  these  old  persons  spoken 
of  by  Dr.  Bence  Jones,  there  were  29  in  all;  eleven  over  60, 


THE  URINE.  143 

and  six  over  70.  Dr.  Eoberts  says  of  this  class : — '  In 
patients  of  this  class  I  ha.ve  generally  found  that  although 
the  diabetic  symptoms  proved  mild  and  amenable  to  treat- 
ment, life  is  seldom  prolonged  beyond  a  few  years.  The 
glycosuria  may  disappear  or  become  insignificant ;  but  the 
constitution  is  evidently  broken,  and  they  die  in  two,  three, 
or  four  years,  either  from  cerebral  disease  or  from  pulmonary 
complications.'  (Group  III.  p.  144.)  From  this  it  is  abun- 
dantly clear  that  glycosuria  may  not  indicate  diabetes,  but 
be  rather  a  prodroma  of  constitutional  failure. 

In  speaking  of  '  Milder  Types  of  Diabetes,'  Roberts  sum- 
marises thus  : — '  The  cases  brought  together  under  this 
heading  are  somewhat  miscellaneous ;  and  they  do  not 
present  those  marks  of  uniformity  which  are  required  to 
constitute  a  homogeneous  pathological  group.  They  are 
separated  from  classical  diabetes  by  certain  broad  dis- 
tinctions of  clinical  importance ;  but  they  exhibit  among 
themselves  certain  disagreements  which  make  it  evident 
they  represent  more  than  one  type  of  disease.  From 
ordinary  or  classical  diabetes  these  milder  types  are  distin- 
guished by  all  or  some  of  the  following  signs  : — Absence  of 
a  fixed  tendency  to  a  fatal  termination ;  absence  or  only  a 
moderate  degree  of  thirst ;  voracity  or  emaciation ;  slight 
or  temporary  increase  in  the  quantity  of  urine  ;  transitory 
duration ;  amenability  to  treatment ;  slight,  moderate,  or 
intermittent  glycosuria.'  He  then  gives  three  groups  into 
one  or  other  of  which  these  cases  usually  fall : 

*  Group  I.  Urine  persistently  saccharine ;  density  1030 
to  1043 ;  diuresis  absent  or  very  moderate ;  no  excessive 
thirst  or  appetite ;  moderate  conservation  of  strength  or 
flesh ;  stationary  conditions. 

'  Group  II.  Glycosuria  temporary  or  intermittent ;  thirst 
or  diuresis  moderate,  or  none ;  little  emaciation  or  loss  of 
strength;  the  complaint  depending  on  mental  anxiety, 
blows  on  the  head,  or  concussion  of  the  spine,  and  ter- 
minating in  complete  recovery. 


144  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

'  Group  III.  Glycosuria  in  persons  advanced  in  years ;  of 
full  habit ;  moderate  conservation  of  flesh  and  strength ; 
moderate  diuresis;  moderate  amount  of  sugar;  abundance 
of  uric  acid  deposits ;  often  gout ;  sugar  sometimes  present 
for  years,  varjdng  greatly  in  quantity,  sometimes  inter- 
mitting ;  termination  variable.'   (See  p,  143.) 

The  subject  has  been  put  before  the  reader  as  fully  as 
the  scheme  of  this  work  will  permit.  Glycosuria  may  be  a 
*  waste-pipe  affair,'  or  a  *  neurosis/  or  a  '  glycosuric  storm  ;' 
or  it  may  be  a  symptom  of  '  classical  diabetes.'  But  at  the 
examination-table  it  is  always  the  last:  unless  it  be  the 
examination  for  the  Membership  of  the  College  of  Physicians 
of  London  ! 

Hsemoglohuline. — When  testing  the  urine  with  nitric  acid, 
and  still  more  on  boiling  it  as  well,  a  pink  hue  is  often 
evolved.  This  indicates  the  presence  of  hsemoglobuline,  or 
'  uro-h?ematine,'  as  it  has  been  termed.  It  usually  occurs 
in  weakly  conditions.  Its  significance  has  not  yet  been 
appraised  ;  and  little  is  said  about  it  in  text-books.  It 
would  seem  to  indicate  a  waste  of  red  blood-corpuscles. 

So  much  then  for  the  modifications  of  the  urine ;  now 
something  may  be  said  as  to  the  information  to  be  gained 
from  the  act  of  passing  it. 

The  Act  of  Passing  Water. — My  own  surgical  knowledge 
having  grown  somewhat  rusty,  application  was  made  to 
Mr.  W.  F.  Teevan,  whose  knowledge  is  unquestionable  on 
this  matter,  from  whom  the  following  observations  are 
taken : — 

In  stone  the  stream  of  urine  is  only  interfered  with 
occasionally  and  suddenly,  from  the  stone  obstructing  the 
urethral  orifice  of  the  bladder.  In  enlarged  prostate  and 
stricture  the  outflow  is  interfered  with  persistently,  and 
sometimes  there  is  actually  retention.  In  enlarged,  prostate 
the  urine  comes  out  '  drop  by  drop,'  and  is  not  projected 
in  front  of  the  patient  by  any  effort  he  can  make ;  while 
there  is  a  dribble  at  the  end  of  the  act  in  the  less  advanced 


THE  URINE.  145 

cases.  In  stricture  there  is  a  small  stream,  but  stream  it 
is,  usually,  with  pain  in  the  act;"  while  in  enlarged  prostate 
the  pain  is  felt  when  the  bowels  move. 

Incontinence  of  urine  may  be  due  to  an  overfull  bladder, 
*  retention  with  dribbling;'  or  it  may  be  due  to  loss  of  power 
in  the  sphincter ;  or  be  associated  with  piles.  It  may  be 
due  to  hysteria ;  though  in  hysteria  inability  to  empty  the 
bladder  is  much  more  common.  It  may  be  due  to  spinal 
injury,  or  to  disease  of  the  brain. 

In  children  it  may  be  due  to  an  irritant  character  of  the 
urine,  which  is  loaded  with  lithic  acid  ;  or  to  irritation  else- 
where causing  the  sphincters  to  relax  in  sleep  ;  or  to  hyper- 
sesthesia  of  the  bladder-centres  in  the  cord. 

Then  there  is  the  matter  of  '  getting  up  at  night  to  pass 
water.'  This  may  be  once,  or  very  frequently.  It  of  course 
depends  to  some  extent  upon  the  amount  of  fluid  imbibed, 
to  the  state  of  the  skin,  and  to  the  character  of  the  urine 
itself.  But  when  it  is  found  as  a  habit,  it  is  held  to  be  sug- 
gestive of  kidney  change ;  and  is  an  important  symptom, 
taken  with  other  semeia.  It  usually  goes  with  the  strong 
heart  and  the  tense  artery.  Sometimes  when  the  person 
has  to  get  up  frequently,  it  is  due  to  an  hypertrophied 
bladder  behind  an  enlarged  prostate  or  a  stricture ;  at  other 
times  its  associations  are  with  disease  of  the  cerebro -spinal 
system. 


10 


CHAPTER  VIII. 

THE    REPRODUCTIVE  ORGANS. 

The  reproductive  organs  in  man  are  comparatively  unim- 
portant to  the  physician;  but  it  is  far  different  with  woman. 
With  man  they  represent  that  surplusage  of  vigour  which 
underlies  the  sexual  passion ;  while  woman,  not  inaptly,  has 
been  spoken  of  as  '  an  organism  around  an  uterus.*     Conse- 
quently the  physician  sees  little  of  the  derangements  of 
these  organs  in  man ;  though  the  surgeon  is  familiar  with 
the   after-consequences   of  youthful   folly,  in   the  form  of 
strictures  of  the  urethra.     But  with  woman,  many  of  her 
maladies  are  linked,  directly  or  indirectly,  with  her  womb 
and  its  surroundings  ;  whether  in  single  or  married  life,  it 
matters  comparatively  little.     Yet,  except  the  grave  cases 
which  engage  the  attention  of  the  obstetric  physician,  the 
student  sees  little  of  the  maladies  of  woman  in  his  hospital 
career  :  probably  finds  the  subject  of  functional  disturbance 
largely  ignored  by  the  ordinary  physicians !     Ignorant  of 
them,  he  enters  practice;    unconscious   of    his    ignorance 
probably,  though  his  female  patients  soon  discover  it,  he  is 
at  length  aroused  to  their  importance,  and  studies  them 
seriously — after  much  lost  time ;  perhaps  after  the  loss  of 
many  patients  who  have  gone  elsewhere,  on  discovering  his 
want  of  familiarity  with  '  female  troubles.'     Such  is  indeed 
the  position  of  most  young  practitioners  on  their  entry  upon 
professional  life. 

It  is  desirable,  then,  that  something  be  said  here  which 


THE  REPRODUCTIVE  ORGANS.  147 

will  help  him ;  for  the   reproductive    organs   are   delicate 
ground,  on  which  it  is  well  to  walk  warily. 

Loss  of  Sexual  Power. — The  sexual  power  is  not  neces^ 
sarily  removed  by  wasting  disease;  indeed,  in  phthisical 
cases,  it  remains  till  very  near  the  end.  It  is  lessened  in 
mitral  disease  ;  and  never  appears  in  the  cyanotic  subjects 
of  congenital  heart  imperfection.  In  diabetes  it  soon  dis- 
appears. All  intense  anxiety  abolishes  it  to  a  large  extent. 
It  is  said  that  a  shrewd  North-country  practitioner  observed 
in  the  Cotton  Famine  of  1SG2,  that  many  of  the  Lancashire 
mill-owners,  face  to  face  with  ruin,  fell  ill,  and  lost  all 
sexual  appetite.  Armed  with  this  knowledge,  he  met  them 
on  the  threshold  of  his  inquiries  by  asking  as  to  their  sexual 
.  vigoui\  Such  a  direct  question  put  so  soon  in  the  interview 
impressed  the  patient  immensely ;  and  it  is  said  that  his 
keen  observation  in  this  matter  secured  him  a  golden 
harvest. 

It  is  much  more  common  to  find  a  young  man  believing 
himself  to  be  impotent  as  a  consequence  of  evil  practices  in 
the  early  days  of  puberty.  If  he  is  about  to  marry,  he  will 
worry  himself  no  little ;  especially  if  a  conscientious,  decent 
fellow !  The  more  he  worries,  the  more  lamentable  his 
condition.  He  is  in  entire  ignorance  of  a  physiological  fact 
to  be  mentioned  immediately,  and  his  conscience  becomes 
morbid  and  overexacting.  He  fully  believes  he  has  lost  his 
manhood ;  especially  if  he  has  been  weak  enough  to  read 
any  of  the  numerous  quack  books  on  the  subject,  which 
harpies  vend  to  prey  upon  human  frailty.  He  is  intensely 
miserable,  and  perhaps  tries  to  put  his  powers  to  the  prac- 
tical test,  with  the  result  of  absolute  failure.  Carpenter 
speaks  of  emotional  impotence  :  '  Here  we  have  a  striking 
example  of  the  utter  powerlessness  of  the  will,  in  the  well- 
known  fact  that  no  amount  of  sexual  desire  will  produce 
erection  if  the  mind  be  possessed  with  any  feeling  of  doubt 
or  apprehension  as  to  the  existence  of  the  sexual  ability.' 
Such  emotional  impotence  of  a  temporary  character  may 

10—2 


148         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

occur  to  any  one,  even  in  perfect  health,  '  Sexual  desire,' 
as  contrasted  with  '  sexual  ability/  is  differentiated  by  Car- 
penter by  italics.  The  distinction  should  be  remembered 
in  all  cases. 

When  there  is  a  catarrhal  condition  of  the  vesiculse 
seminales,  then  a  glairy  fluid  is  poured  out  after  the  act  of 
micturition,  and  still  more  on  defsecation,  from  the  local 
pressure.  These  conditions  rarely  create  any  alarm,  except 
when  the  conscience  is  implicated. 

A  man  may  have  no  power  of  erection,  and  yet  have 
sexual  desire  with  perfect  semen.  At  other  times  the  sexual 
act  is  normal,  but  no  result  follows  from  absence  or  imper- 
fect development  of  the  spermatozoa.  Or  a  couple  may  be 
childless  and  separate  to  mate  with  others  ;  when  the  female 
becomes  prolific,  while  the  male  is  gratified  by  being  a  sire. 

Increase  of  the  Sexual  Power. — This  is  termed  priapism  in 
aggravated  forms.  It  may  be  the  result  of  convalescence 
from  acute  disease,  notably  yellow-fever ;  or  it  may  result 
from  cantharides  having  been  used  intentionally,  or  by  acci- 
dent. It  may  be  set  up  by  disease  in  the  posterior  occipital 
lobes ;  or,  in  its  most  marked  form,  it  may  be  due  to  frac- 
ture of  the  spinal  column  in  the  lumbar  region.  In  the 
early  stages  of  tabes  dorsalis,  otherwise  locomotor  ataxy, 
the  sexual  power  is  often  markedly  increased,  especially  in 
the  Arab  type  of  man  (p.  11).  In  vesical  calculus  the  ardor 
veneris  is  sometimes  very  pronounced  in  paroxysms,  accom- 
panied by  acute  pain. 

In  woman  the  disturbance  of  the  sexual  feelings  is  less 
indicative  of  disease,  or  disorder  than  is  the  case  with  man. 
Local  causes,  as  seat- worms,  affect  both  sexes  alike ;  but  if 
a  thread-worm  creeps  into  the  vaginal  orifice,  it  will  excite 
the  most  pronounced  local  irritation  with  a  corresponding 
psychical  attitude.  Local  causes  of  pruritus  are  often  trouble- 
some as  eczema,  especially  when  due  to  the  sugar-laden 
urine  of  diabetes.  Consumptive  girls  are  salacious,  while 
the  opposite  is  the  case  with  the  subjects  of  valvular  disease 


THE  REPRODUCTIVE  ORGANS.  149 

of  the  heart ;  much  of  course  depending  upon  temperament. 
Kich  food,  luxurious  couches,  and  foul  fiction  are  respon- 
sible for  much  sexual  excitement  in  young  women,  that 
could  very  well  be  dispensed  with.  This  fouling  of  the 
mind  is  the  exciting  cause  of  much  that  is  injurious  and 
undesirable ;  and  whether  relief  be  sought  in  normal  or 
abnormal  ways,  or  unchaste  thought  be  co-existent  with 
bodily  purity,  this  toying  with  the  sexual  feelings  is  to  be 
condemned ;  and  is  often  to  be  deplored. 

Of  course  it  is  when  budding  into  puberty  that  the  mental 
perturbation  caused  by  the  inrush  of  novel  and  absorbing 
ideas  is  most  marked ;  but  great  sexual  excitement  may 
mark  the  involution  as  well  as  the  evolution  of  repro- 
ductive activity,  after  which  woman  glides  into  a  sexless 
existence. 

There  is  no  subject  which  will  make  greater  demands 
upon  the  reflective  powers  of  the  practitioner  than  the 
sexual  instinct.  Some  put  it  aside  as  if  something  unclean 
and  unmentionable ;  others  fall  back  upon  it  at  once  and 
instinctively  as  the  ever-acting  cause  of  all  disturbance  of 
the  health  that  cannot  readily  and  obviously  be  accounted 
for.  Both  extremes  are  foolish,  while  the  latter  is  often 
grossly  unfair.  The  introduction  to  the  Marriage  Service 
of  the  Church  of  England  tells  of  a  coarse  age ;  and,  still 
more,  of  that  curious  meddling  with  the  sexual  instinct  to 
which  the  celibate  clergy  of  Rome  have  ever  been  addicted. 
The  sexual  instinct  has  not  to  be  banned  by  the  priest ;  but 
intelligently  comprehended  by  the  physiologist-physician. 

The  Catamenia. — When  puberty  is  reached  by  women, 
psychical  changes  are  the  correlative  of  physical  develop- 
ment, and  rhythmic  flows  from  the  generative  organs  are 
established.  This,  really,  represents  the  surplus  wave  of 
nutrition,  as  it  is  aptly  termed.  That  is,  the  organism  is 
now  sufticiently  developed  to  take  on  new  duties,  to  which 
it  is  urged  by^  novel  promptings.  But  it  just  happens  in 
this  imperfect  world  that  this   new  demand    often  comes 


ISO         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

somewhat  earl}'-  and  before  the  need  for  it  is  apparent.  It 
would  be  infinitely  better  for  the  child- wives  of  India  if 
puberty  were  longer  delayed  with  thera.  In  our  own 
climes  puberty  comes  all  too  soon  with  many,  and  the  new 
body-expenditure  arrests  the  growth  and  stunts  the 
organism ;  while  the  mind,  not  yet  sufficiently  developed 
to  sustain  the  impetus  of  the  sexual  passion,  reels  under  it 
and  becomes  depraved.  Especially  is  this  the  case  when  a 
premature  development  takes  place  amidst  an  unclean  en- 
vironment, and  the  mind  is  debauched  by  what  it  is  sur- 
rounded by.  Children  have  not  pure  minds  always  ;  and 
the  premature  advent  of  puberty  to  impure-minded  children 
has  been  described  by  Maudsley  thus  : — '  Given  an  ill-consti- 
tuted or  imperfectly  developed  brain  at  the  time  when 
the  sexual  appetite  makes  its  appearance,  and  what  is  the 
result  ?  None  other  than  that  which  happens  with  the 
lower  animals — simply  lust.  While  servants  are  not  all 
endowed  with  self-respect,  a  French  bonne  is  a  moral  plague 
very  often  to  her  young  charges,' 

In  other  girls  the  pubertal  changes  produce  little  disturb- 
ance, physical  or  psychical,  and  growth  goes  on  apace. 
The  well-grown,  well-developed  girl,  who  is  so  attractive  to 
the  opposite  sex,  is  cleanly-minded,  as  well  as  pure  bodily ; 
because  pubertal  changes  have  not  overwhelmed  her,  as  is 
the  case  with  many  small  girls.  This  matter  has  a  great 
deal  to  do  with  the  mental  traits  of  small  girls,  as  com- 
pared to  those  of  well-grown  girls.  To  a  less  extent,  the 
same  may  be  said  of  man — making  all  allowances  for 
families  of  small  stature,  as  well  as  for  races  which  are 
undersized. 

It  is  well  then  to  inquire  when  the  catamenia  appeared ; 
whether  they  are  regular  or  irregular,  scanty  or  profuse; 
whether  indeed  the  generative  expenditure  is  great  or  small, 
little  or  excessive.  This  will  throw  much  light  on  many  a  case. 
For  instance,  a  young  woman  is  supposed  to  be  phthisical, 
and  has  a  persistent  and  suggestive  cough.    But  on  inquiry 


THE  REPRODUCTIVE  ORGANS.  151 

it  is  found  that  she  is  profusely  unwell,  eight  days  every 
three  weeks,  with  considerable  leucorrhoea.  It  only  needs 
the  condition  of  night  sweating  to  be  added  to  this,  and 
then  the  physical  signs  of  lung  trouble  will  not  be  long  in 
making  themselves  manifest.  My  experience,  as  physician 
to  a  chest-hospital,  tells  me,  in  unmistakable  accents,  that  if 
careful  inquiry  into  the  general  condition  preceded  physical 
examination,  no  matter  how  precise,  in  a  great  many  in- 
stances, a  truer  estimate  of  the  nature  of  the  case  would  be 
formed.  It  might  dawn  upon  some  minds  under  these  circum- 
stances that  the  lung-mischief  is  not  so  much  the  cause,  as 
the  consequence  of  the  state  of  the  general  health  !  Women 
themselves  never  underrate  the  importance  of  the  cata- 
menial  discharge ;  its  arrest,  or  its  excess.  Some  indeed  go 
to  the  opposite  extreme  to  some  young  medicos ;  and  if 
these  last  almost  forget  to  consider  that  '  physiologically  a 
woman  is  an  organism  around  a  uterus,'  these  women  seem 
never  to  be  able  to  forget  this  fact. 

AmenorrhcBa. — The  menstrual  discharge  may  never  be  es- 
tablished ;  sometimes  from  lack  of  the  requisite  organs, 
more  commonly  from  lack  of  developmental  energy.  Thus 
the  cyanotic  victims  of  congenital  imperfect  evolution  of  the 
heart  may  live  to  tlie  years  of  puberty,  but  they  never  accom- 
plish the  pubertal  changes ;  so  far  as  I  have  been  able  to 
learn.  Then  weakly  dwarfed  children  have  no  surplus  wave 
of  nutrition  to  take  the  form  of  the  catamenia.  In  some 
families,  fortunately  for  them,  pubertal  changes  are  late  in 
appearing.  In  other  cases  there  is  much  disturbance  of 
the  health,  indicating  the  perturbations  which  herald  the 
appearances  of  the  menses  ;  and  the  girl's  mother  earnestly 
pleads  :  '  If  you  could  only  bring  them  on,  sir,  I  am  sure 
she  would  be  better.'  Quite  so :  if  there  was  any  way  of 
bringing  them  on  except  that  of  raising  the  body-income 
till  a  surplus  wave  is  possible.  To  attempt  by  oxytoxics  to 
start  the  catamenial  life  in  an  ill-nourished  girl  would  be 
as  unwise  as  it  would  probably  be  abortive.     Is  it  desirable 


152         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

to  call  into  existence  a  new  demand  upon  an  ill-nourished 
organism  ?  Reason  can  answer  the  question.  Fortunately, 
it  is  scarcely  possible  to  achieve  such  an  undesirable  con- 
summation ! 

Then  there  is  what  may  be  called  '  conservative  amenor- 
rhoea/  that  is  a  cessation  of  the  menses,  because  the  system 
can  no  longer  afford  such  a  body-expenditure.  Nature 
stops  off  this  extragavance,  as  it  becomes  under  the  circum- 
stances of  malnutrition.  Here  the  arrest  of  this  mensual 
outgoing  is  most  desirable,  and  is  followed  by  systemic 
development.  The  body-income  becomes  equal  to  the  body- 
expenditure  ;  and  something  more.  It  is  easy  to  allay  the 
maternal  anxieties  when  the  case  is  put  clearly.  Unfortu- 
nately, in  many  cases,  this  piece  of  conservatism  is  not 
accomplished,  and  the  organism  suffers.  Here  the  outflow 
is  too  frequently  maintained  by  habits  and  by  thoughts 
which  keep  up  a  state  of  high  vascularity  in  the  generative 
organs ;  for  erectile  tissue  is  not  confined  to  the  male.  The 
system  here  is  subordinated  to  the  generative  expenditure, 
and  suffers  accordingly.  In  the  struggle  betwixt  nutrition 
and  the  reproductive  energies,  the  nutrition  fails.  A  curious 
illustration  of  the  antagonism  of  nutrition  and  reproduction 
is  seen  in  the  sterility  of  prize  heifers  which  have  been  un- 
duly fattened  all  along  ;  and  another  is  the  stunted  pine, 
covered  with  abortive  cones,  as  compared  to  the  few  but 
perfect  cones  of  a  more  healthy  tree.  The  dwarfed  fir-tree 
covered  with  abortive  cones  corresponds  closely  to  the 
stunted  girl,  when  her  generative  expenditure  has  got  ahead 
of  her  body  income.  When  the  catamenial  loss  is  excessive, 
its  comparative  arrest  is  followed  by  great  general  improve- 
ment. How  can  this  excessive  demand  be  brought  about,  it 
may  be  asked  ?  How  can  a  surplus  wave  of  nutrition  be 
transformed  into  an  excessive  drain  upon  the  system  ?  That 
such  is  the  clinical  fact  is  unquestionable  ;  however  defective 
the  explanation  may  be  !  In  some  cases  an  irritable  ovary 
may  keep  the  generative  organs  in  a  state  of  high  vascu- 


THE  REPRODUCTIVE  ORGANS.  153 

larity,  of  which  menorrhagia  and  leucorrhoea  are  the  out- 
comes. 

It  is  highly  desirable  that  these  relations  of  the  generative 
expenditure  to  the  body  nutrition  be  carefully  thought  out ; 
because  if  this  be  thoroughly  done^  the  rightline  of  treatment 
will  suggest  itself  in  many  cases,  otherwise  not  easily  dealt 
with.  The  correct  diagnosis  indeed  is  fertile  in  result ;  but 
an  imperfect  diagnosis  is  as  sterile  as  the  stunted  pine  just 
spoken  of. 

Amenorrhoea  is  physiological  in  the  states  of  preg- 
nancy and  lactation ;  though  this  is  not  invariably  the  case. 
So  long  as  the  menses  do  not  occur  in  lactation,  so  long  is 
that  woman  barren ;  as  many  women  know  well,  and  who 
decline  to  wean  their  children  accordingly.  In  others,  suck- 
ling confers  no  such  protection  against  impregnation.  Fe- 
cundity and  the  sexual  appetite  have  no  definite  relation 
to  each  other.  Then  the  menses  cease  when  the  repro- 
ductive life  reaches  its  close,  and  this  may  occur  early — 
in  one  case  known  to  me,  at  twenty-six — or  be  delayed. 
When  in  general  practice,  I  attended  a  woman  in  child- 
birth at  fifty-one.  Usually,  the  menopause  occurs  at 
forty-five.  The  normal  period  of  the  reproductive  life 
of  a  woman  in  the  temperate  zones  is  thirty  years  (from 
fifteen  to  forty- five). 

It  was  long  held  that  menstruation  corresponded  to 
ovulation.  That  they  are  closely  connected  may  not  be 
denied.  But  that  menstruation  depends  on  ovulation  is 
contradicted  by  the  fact  that  menstruation  may  go  on  after 
the  removal  of  both  ovaries.  Such  a  removal  does  not 
unsex  a  woman ;  but,  of  course,  it  renders  her  sterile. 

Menorrhagia. — The  catamenia  may  be  said  to  cover  four 
days  of  the  mensual  cycle  of  twenty-eight  days.  For 
twenty-four  days  a  gradual  ascent  is  made,  while  the 
descent  occupies  a  much  briefer  period.  It  is  commonly 
spoken  of  as  '  the  menstrual  week  of  the  catamenial  cycle.' 
But   the   catamenia   may  continue  more  than  four  days; 


154  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

while  the  cycle  is  much  less  than  a  lunar  month.  The 
catamenia  may  last  a  week  and  come  on  every  twenty-one 
days,  or  even  every  fourteen  days.  They  may  even  he  the 
last,  and  be  profuse  too.  Here,  of  course,  it  is  abundantly 
clear  that  whatever  be  the  ostensible  malady  complained  of 
by  the  patient,  this  excessive  loss  is  what  the  doctor  must 
attend  to  for  successful  treatment.  When  that  has  been 
arrested  the  more  especial  malady  may  be  the  object  of 
therapeutic  attack  ;  or  the  two  may  admit  of  a  combined 
treatment.  When  there  is  mal-nutrition  the  arrest  of  the 
drain  will  add  materially  to  the  body-gain — 'a  penny 
saved  is  a  penny  gained.'  Indeed,  to  check  the  loss  is 
often  a  more  important  matter  than  to  raise  the  body 
income. 

Dysmenorrhoea,  —  Great  suffering  may  accompany  the 
menstrual  act.  In  some  cases  the  suffering  is  chiefly  before 
the  loss  comes  on ;  in  others,  it  continues  through  the 
period.  The  suffering  is  usually  much  diminished  towards 
the  end  of  the  flux.  It  is  difficult  in  some  cases  to  say 
which  taxes  the  system  most;  the  loss  of  blood,  or  the  loss  of 
nerve-energy  from  the  severe  pain.  For  instance,  in  many 
cases  the  oleum  Pulegii  gives  great  and  pronounced 
relief  from  suffering ;  but  this  is  counterbalanced  by  the 
increase  in  the  flux  in  some  instances,  so  that  it  becomes 
a  question  whether  it  is  desirable  to  resort  to  the  penny- 
royal, or  not. 

Dysmenorrhoea  may  be  due  to  a  narrowing  of  the  neck 
of  the  womb,  or  to  clots  blocking  the  orifice.  Here 
recurrent  pains,  resembling  the  bearing-down  pains  of 
parturition,  are  present;  and  when  a  clot  is  the  offending 
cause,  the  paroxysm  may  cease  with  a  gush  of  blood. 

Dysmenorrhoea  is  infinitely  more  common  as  due  to 
some  ovarian  condition.  The  ovary  is  tender,  sometimes 
enlarged.  The  perturbations  so  excited  manifest  them- 
selves throughout  the  whole  system  ;  the  nerve-waves  set 
up  in  the  ovary  may  break  on  any  terminal  nerve  fibres. 


THE  REPRODUCTIVE  ORGANS.  155 

When  a  number  of  balls  are  suspended  in  a  row  touching 
each  other,  and  a  tap  be  given  to  one  at  the  outside,  it  is 
the  ball  at  the  other  end  which  flies  from  its  place :  the 
impetus  has  been  transmitted  from  one  to  the  other  till  at 
last  the  transmission  becomes  impossible,  and  the  impetus 
drives  the  outside  ball  from  its  place.  So  the  waves  of 
nerve  perturbation  started  in  the  ovary  may  terminate,  for 
instance,  in  the  peripheral  fibrils  of  an  intercostal  nerve, 
and  are  felt  by  the  patient  as  gusts  of  neuralgic  pain.  Or 
they  may  extend  to  the  stomach,  and  cause  vomiting.  The 
range  of  such  ovarian  disturbance  is  as  follows,  so  far  as 
my  experience  goes.  The  occipital  lobes  are  affected,  as  is 
commonly  the  case  with  pelvic  trouble  (p.  121),  and  the  pa- 
tient feels  depressed  and  is  disposed  to  cry ;  while  there  is 
vertical  headache.  There  is  intercostal  pain  with  the  three 
tender  spots  of  Valleix  :  one  at  the  left  apex,  the  most 
marked  one ;  a  second  at  the  outer  edge  of  the  scapula  ; 
and  the  other  at  the  point  of  ingress  of  the  posterior  sensory 
root  at  the  spinal  foramen.  There  may  be  palpitation ;  less 
commonly,  some  depression  of  the  heart's  action.  There  is 
constipation  reflexly  produced  (p.  121)  ;  while  the  patient 
is  liable  to  paroxysms  of  irritation,  or  dryness  and  itching 
of  the  anus ;  or  even  of  the  vagina  as  well,  in  some  cases. 
The  uterus  and  its  appendages  are  kept  in  a  state  of  high 
vascularity;  while  orgasm  is  frequent,  especially  during 
sleep,  '  the  period  jiar  excellence  of  reflex  excitability.' 
Frequently  the  bladder  centres  become  implicated,  and  the 
patient  is  unable  to  hold  her  water.  Thus  we  see  a 
distinct  grouping  of  symptoms  quite  intelligible.  When 
the  ovary  lies  to  the  side  (usually  the  left)  it  is  close  to  the 
bowel,  and  pain  accompanies  the  act  of  defsecation;  when 
near  the  mesial  line  the  pain  is  associated  with  the  act  of 
micturition.  Commonly,  bearing-down  pains  are  com- 
plained of.  Such  is  the  tout-ensemhle  of  a  malady  very 
commonly  seen — when  the  mental  eye  has  learned  to  see  it, 
with  well-marked  characters  too.     But  it  has  not  yet  made 


156         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

its  way  into  text-books ;  or  even  into  a  medical  curri- 
culum, except  the  rooms  of  some  of  our  obstetric  physicians. 
Yet  the  recognition  of  this  many -linked  malady  will  stand 
the  practitioner  in  good  stead  many  a  time  and  oft;  if,  that 
is,  he  will  take  the  trouble  to  learn  to  recognise  it.  He  will 
not  encounter  it  at  the  examination  table  in  theory,  or  find 
such  a  case  a  part  of  his  clinical  examination,  in  all  proba- 
bility: but  Dame  Nature  will  bring  the  case  before  him 
frequently  enough,  as  an  increasing  experience  will  tell  the 
reader ;  who  perhaps  on  first  reading  this  feels  an  im- 
pression that  the  whole  is  a  flight  of  my  imagination — and 
a  lofty  flight  too  ! 

Here  there  is  great  suftering  at  the  menstrual  week ;  in- 
deed, the  patient  may  roll  on  the  floor  in  agony,  just  as  much 
as  in  the  obstructive  form  of  dysmenorrhoea.  There  is  much 
suff"ering  also  in  the  intra-menstrual  interval.  The  treat- 
ment of  maladies  is  no  part  of  my  present  scheme  ;  but  the 
facts  are  arranged  so  as  to  suggest  the  rational  treatment. 

Leucorrhoea. — Like  all  other  mucous  membranes,  that  of 
the  vagina  and  uterus  is  liable  to  catarrhal  states.  A  dis- 
charge may  be  due  to  infection  (gonorrhoeal) ;  or  be  a  mere 
blenorrhagia  due  to  irritation,  as  coitus,  or  to  a  want  of 
habits  of  cleanliness.  Or  it  may  be  a  flux  associated  with 
atonic  states  of  the  system.  Such  '  whites  '  or  '  weakness,' 
as  it  is  variously  termed,  is  itself  very  debilitating  when 
excessive.  Sometimes  such  leucorrhceal  condition  exists 
during  the  whole  of  the  interval  betwixt  the  menstrual 
periods,  which  may  be  excessive.  At  other  times  the 
menstrual  flux  seems  lost  in  the  discharge  till  the  periods 
are  not  distincruishable  at  all.  Such  a  blenorrhacria  in  woman 
may  set  up  a  urethritis  in  the  male  having  coitus  with  her ; 
without  any  grounds  for  suspicion  of  its  being  gonorrhoeal, 
on  either  side.     A  fact  not  generally  known ! 

It  must  be  borne  in  mind,  however,  in  all  losses  bearing 
on  the  generative  expenditure,  that  there  is  a  loss  of  a 
highly  elaborate  fluid,  whether  semen  or  the  secretion  of 


THE  REPRODUCTIVE  ORGANS.  157 

the  female  glands  (the  glands  of  Naboth  or  those  of 
Duvernay),  or  mere  mucus;  not  only  that,  v/ith  much  of 
this  there  is  a  great  nervous  expenditure.  And  this  last  it 
is  which  exliausts  the  nervous  system.  This  is  seen  in 
persons  of  abandoned  habits  in  either  sex !  they  seem  to 
have  lost  all  capacity  for  intellectual  pleasure,  or  indeed 
corporeal  pleasure ;  except  that  which  is  attendant  upon  the 
reproductive  instinct — their  life  is  reduced  to  a  sensual 
dream.  A  condition  not  confined  to  lunatic  asylums,  or 
even  retreats.  It  is  the  life  of  the  ape  indeed.  Imbeciles 
and  idiots  resemble  the  ape  in  their  persistent  indulgence 
of  the  sexual  appetite,  in  season  and  out  of  season.  While  in 
others  the  repression  of  their  instincts  seems  to  blight,  or 
deform  the  whole  character. 


I 


CHAPTER  IX. 

THE   TESEPERATURE. 

One  of  the  most  valuable  additions  to  our  means  of  correctly 
estimating  the  real  condition  of  a  patient  is  the  clinical 
thermometer.  When  the  '  Treatise  on  Medical  Thermo- 
metry,' by  Wunderlich,  was  translated  by  the  Sydenham 
Society,  most  of  us  wakened  up  to  the  conviction  that  a 
new  and  important  light  was  thrown  upon  disease.  Of 
course  the  matter  was  not  unknown  to  many  before  this ; 
but  the  general  awakening  of  the  profession  at  large  to  the 
fact  dates  from  then  (1871).  The  subject  is  now  very 
thoroughly  taught  in  hospitals ;  but  as  possibly  some  of 
my  readers  who  entered  the  ranks  of  the  profession  anterior 
to  that  time,  may  like  to  have  a  brief  resume  on  this  im- 
portant subject ;  it  seems  desirable  to  add  such.  The 
attempt  will  be  made  to  so  arrange  the  matter  as  to  enable 
the  practitioner  to  think  rationally  over  his  observations. 
A  medical  man  is  something  more  than  •  a  mere  sense- 
machine  for  registering  observations,'  as  Maudsley  pithily 
puts  it.  Unless  he  do  reflect  thoughtfully,  he  will  lose 
much  of  the  advantage  he  may  gain  from  the  little  instru- 
ment. 

In  the  first  place,  he  must  realize  that  many  maladies  do 
not  affect  the  temperature  ;  while  others  do.  All  febrile  and 
inflammatory  affections  produce  a  rise  of  temperature ;  while 
others,  like  diarrhoea  or  asthma,  decrease  the  body-tempera- 
ture.   When  haemorrhage  from  the  bowels  is  taking  place  in 


THE  TEMPERATURE.  159 

typhoid  fever,  the  temperature  suddenly  drops;  conse- 
quently a  sudden  fall  in  the  temperature  in  enteric  fever 
puts  the  medical  man  upon  his  guard  as  to  this  accident, 
without  waiting  to  see  blood  appear  per  anum.  On 
the  other  hand,  when  in  a  pyretic  affection  the  temperature 
suddenly  runs  very  high — over  105°  Fahr.— then  a  condition 
of  hyperpyrexia  is  setting  in  ;  which  will  probably  be 
quickly  fatal. 

The  time  consumed  for  a  thermometric  examination 
should  not  be  less  than  five  minutes.  Consequently 
it  is  very  evident  that  very  busy  practitioners  must 
limit  their  thermometric  observations  in  many  instances. 
It  is  in  the  full  conviction  that  this  is  inevitable  that  I 
have  urged  before  (p.  57)  the  use  of  the  watch  in  order 
to  tell  more  quickly  what  is  probably  going  on.  Fifty 
years  ago,  the  pulse  was  invariably  carefully  counted ;  and 
a  rise  or  fall  was  regarded  as  of  much  import.  Such  an 
observation  can  be  taken  fairly  in  half  a  minute.  If  each 
practitioner  in  his  early  days  of  practice,  before  he  becomes 
a  busy  man,  would  learn  to  note  the  relation  between  what 
the  watch  tells  and  what  the  thermometer  has  to  say,  he 
would  find  it  of  infinite  service  to  him  when  the  demands 
upon  his  time  become  numerous.  The  watch  might  be  found 
often  to  tell  him  that  the  thermometer  should  be  used; 
sometimes,  doubtless,  that  it  may  be  dispensed  with.*  But 
it  may  be  pleaded  the  pulse  varies  so  much  with  excitement 
or  nervousness.  Certainly;  but  is  this  not  equally  true  as 
to  the  temperature  ?  Some  time  ago,  a  case  came  under 
my  notice  where  Dr.  Green,  of  Sandown,  I.W.,  had  found 
the  temperature  always  at  least  103°  Fahr.  when   taken. 

*  '  In  surgery,  as  in  physic,  with  a  high  temperature,  we  have,  as  a 
rule,  a  correspondingly  rapid  pulse  and  respiration.  In  health  the 
proportion  borne  between  pulse  and  respiration  is  stated  generally  at 
4  to  1  in  the  adult ;  this  proportion  is  not  materially  influenced  by 
disease,  except,  contrary  to  what  one  would  suppose,  in  low  tempera- 
tures.'— McFiE  Campbell. 


1 


i6o         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


Yet  there  was  nothing  in  the  progress  of  the  case  to  war- 
rant such  a  temperature,  which  went  on  for  months.  (See 
chap,  xii.,  on  the  effects  of  high  temperatures.)  The  patient 
was  a  girl  of  highly  neurosal  temperament — indeed,  just 
one  of  those  beings  who  seem  made  to  mislead  doctors. 
Having  occasion  to  visit  her  at  her  home,  she  was  found 
comfortably  seated  in  an  arm-chair,  dressed,  looking  very 
nicely,  in  high  spirits,  with  some  excitement  perhaps.  On 
taking  her  temperature,  it  was  found  to  be  no  less  than 
104°.  Taken  in  connection  with  what  Dr.  Green  had 
observed,  it  was  clear  this  was  a  passing  neurosal  tempera- 
ture. The  case,  indeed,  was  one  of  malnutrition  ;  where, 
according  to  all  known  laws,  there  should  have  been  a  sub- 
normal temperature,  not  a  high  one.  There  was  a  corre- 
sponding acceleration  of  the  respiration  and  the  pulse. 
Now,  if  the  watch  was  not  to  be  relied  on  here,  neither 
was  the  clinical  thermometer.  Nor  is  such  case  an  isolated 
one.  It  merely  proves  that  with  all  instruments  of  precision 
thought  is  requisite.  '  It  is  not  the  instrument  that  knows,' 
is  the  remark  of  one  of  the  soundest  old  practitioners  with 
whom  the  writer  is  acquainted. 

As  the  reader  may  think  that  such  a  case  is  too  uncommon 
to  carry  with  it  any  practical  significance,  it  may  be  well  to 
see  what  Austin  Flint  says,  as  no  one  will  be  venturesome 
enough  to  doubt  his  statements  :  '  The  physician  is  liable  to 
be  misled  by  placing  too  much  reliance  on  the  laws  of 
temperature.  They  are  not*  infrequently  interfered  with  by 
complications  and  accidental  events.  As  an  illustration,  a 
young  girl  had  passed  through  typhoid  fever,  convalescence 
being  declared,  in  connection  with  other  symptoms,  by  the 
laws  of  thermometry  belonging  to  the  decline  of  fever  or 
defervescence  in  this  disease.  Suddenly,  hysterical  symp- 
toms were  manifested,  and  the  temperature  rose  to  105°. 
The  physician,  a  man  of  learning  and  large  experience,  was 
naturally  alarmed.  In  a  few  hours,  however,  the  tempera- 
ture  declined,   and   recovery    took   place   without  further 


THE  TEMPERATURE.  i6i 

impediment.  The  expressive  comment  made  by  the  physi- 
cian was,  "This  is  not  the  first  time  I  have  been  fooled  by 
temperature."  With  regard  to  the  information  furnished 
by  the  thermometer,  as  well  as  to  other  diagnostic  symp- 
toms, it  is  to  be  borne  in  mind  that  there  are  exceptions  to 
rules  which  are  generally  applicable.'  When  then  the 
temperature  is  found  to  be  higher  than  other  evidences  seem 
to  warrant,  the  case  requires  thought.  If  found  in  a  young 
woman  of  the  hysterical  type,  it  is  probably  a  neurosis. 
Under  other  circumstances  it  may  mean  no  more  than 
acute  indigestion,  a  very  common  cause  of  a  sharp  rise  of 
temperature.  While  at  other  times  it  is  an  hyperpyrexia, 
gravely  threatening  life.  It  is  expecting  too  much  of  an 
instrument  to  suppose  for  a  moment  that  it  could  give  any 
suggestion  as  to  what  the  relations  of  the  sudden  rise  are. 
The  brain  of  him  that  wields  it  might,  however,  solve  the 
problem  ! 

It  is  well,  therefore,  to  have  some  definite  ideas  as  to  the 
relation  of  the  body-temperature  to  certain  states.  Rosen- 
thal has  divided  the  body  into  two  areas,  (1)  the  internal, 
or  '  heat-making '  area  ;  and  (2)  the  external,  or  '  heat-losing  ' 
area.  In  cold  weather  the  cutaneous  vessels  are  contracted, 
and  the  surface  is  marbly,  by  which  the  heat-loss  is  reduced 
to  a  minimum.  At  the  same  time  there  is  high  vascularity 
in  the  internal  area  with  consequent  increased  heat-pro- 
duction. Such  is  the  mode  by  which  the  body-temperature 
is  maintained  in  cold.  Clothes  lessen  the  heat-loss,  and  the 
Eskimo  is  clad  in  furs.  In  hot  weather  the  skin  is  highly 
vascular,  and  the  cutaneous  area  is  full  of  blood  ;  conse- 
quently there  is  great  heat-loss.  The  external  area  being 
full  of  blood,  the  internal  area  is  correspondingly  depleted; 
and  therewith  heat-production  is  lessened.  Further,  the 
vascular  skin  increases  the  perspiration,  and  then  the  cool- 
ing efiects  of  the  evaporation  of  water  are  added.  That  is, 
there  is  diminished  heat-production  with  increased  heat- loss, 
so  as  to  keep  the  body  cool.     In  the  tropics  the  natives  wear 

11 


i62         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

little  more  than  a  breech-clout ;  for  decency,  not  warmth ! 
The  effects  of  perspiration  on  the  heat-loss  must  be  borne 
in  mind;  and  then  the  practitioner  will  never  underestimate 
the  significance  of  a  high  temperature  with  a  moist  skin. 
A  moist  skin  with  pyrexia  means  a  heat-loss  much  beyond 
what  is  normal ;  yet  there  is  still  pyrexia,  and  consequently 
the  heat-production  must  be  enormous. 

Pyrexia  may  be  due  to  diminished  heat-loss,  or  in- 
creased heat-production,  or  both.  In  the  rising  fever  of 
the  exanthemata,  and  other  febrile  conditions,  the  perspira- 
tion is  almost  nil ;  and  the  fever  is  due  mainly  to  defective 
heat-loss.  In  rheumatic  fever  the  skin  is  usually  moist,  or 
even  wet ;  and  yet  the  temperature  is  above  the  normal. 
Here  heat-production  must  be  great.  (The  importance  of 
recognising  the  distinction  betwixt  a  '  dry  skin '  and  a  '  wet 
skin '  pyrexia  as  regards  the  indications  for  treatment,  is 
considered  fuUy  in  the  chapter  on  '  Body-Heat  and  Fever  ' 
in  '  The  Practitioner's  Hand-book  of  Treatment,^  or  '  The 
Principles  of  Therapeutics,'  2nd  ed.,  1880.)  In  estimating 
the  pyrexial  rise  of  temperature  the  practitioner  should 
never  overlook  the  significance  of  a  '  wet  skin,'  as  compared 
to  a  '  dry  skin.'  Without  such  consideration  his  mere 
observation  of  the  actual  body-temperature  is  imperfect. 

Pyrexia  then  may  be  due  to 

1.  Imperfect  heat-loss. 

2.  Increased  heat-production. 

3.  Both  combined. 

Beyond  this  there  is  the  condition  where  the  heat-loss  is 
larger  than  is  normal ;  yet,  nevertheless,  the  heat-production 
is  still  farther  in  excess  over  what  is  normal.  This  last 
tells  of  a  far  graver  condition  than  the  dry  skin  of  rising 
fever.  J 

Then  there  are  other  relations  of  pyrexia  to  remember. 
In  children  the  temperature  is  mobile,  and  a  rise  is 
readily  produced.  While  as  age  goes  on  this  mobility  de- 
creases, and  a  rise  of  temperature  in  old  persons  is  gravely 


THE  TEMPERATURE.  163 

significant.  A  rise  of  two  or  three  degrees  in  a  child  is 
of  little  moment;  in  a  person  over  sixty  it  is  decidedly 
ominous. 

Then  there  is  the  rapidity  of  the  rise.  In  acute  indi- 
gestion the  rise  is  swift  to  103°  or  104%  or  even  105°;  and 
the  defervescence  equally  rapid.  In  fevers  the  rise  is  at- 
tained much  more  slowly,  taking  as  many  days,  as  a  rule,  as 
indigestion  takes  hours ;  while  the  defervescence  is  pro- 
portionately slow.  A  very  sharp  rise  from  a  condition  of 
health  is  very  suggestive  of  acute  indigestion  ;  though  it 
may  mean  insolatio.  Sunstroke  is  seen  even  in  England ; 
but  only  in  our  hottest  weather,  and  in  those  exposed  to  the 
sun,  as  field-hands.  A  person  with  an  ill-developed  nervous 
system,  or  depressed  from  any  cause,  mental  or  bodily,  is 
much  more  liable  to  a  rapid  temperature-disturbance  from 
sunstroke  than  others  with  more  resistent  nervous  systems. 

The  normal  temperature  of  the  body  may  be  stated  to  be 
from  98'5°  to  99°  Fahrenheit.  A  variation  of  several  degrees 
upwards  to  101°  is  not  incompatible  with  health.  If  the 
individual  be  ill,  then  the  rise  to  101°,  or  even  less,  may  be 
a  distinct  febrile  temperature.  A  fall  to  97°,  or  more,  may 
occur  from  vomiting,  or  diarrhcea,  without  its  being  classed 
as  an  abnormal  temperature. 

But  when  the  temperature  rises  persistently  over  99'5°  it 
is  called  '  febrile,  but  low.'  When  101°  is  reached  it  is 
'febrile';  when  102°  is  reached  the  temperature  is  called 
'  high  ' ;  when  104°  is  reached  it  is  '  very  high  ' ;  and  beyond 
105°  it  reaches  'hyperpyrexia,'  and  life  is  in  danger;  in- 
creasing with  every  degree  up  to  108°,  which  may  be  re- 
garded as  '  the  limit  compatible  with  recovery ;'  though  a 
few  carefully  observed  trustworthy  cases  are  on  record  of  a 
recovery  from  a  temperature  of  110°.  The  notorious  Scar- 
borough case  when  for  seven  weeks  the  temperature  ranged 
from  108°  to  110°,  at  one  time  reaching  122°,  was,  in  every 
way,  too  queer  a  case  to  have  any  scientific  value. 

Then  when  the  temperature  falls  below  96°  it  is  termed  a 

11—2 


164 


PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


'  collapse '  temperature ;  and  below  93^  there  is  '  algide 
collapse.' 

Collapse, —  This  varies  from  the  subnormal  temperature 
found  with  asthma,  emphysema,  cardiac  lesions,  and  some 
forms  of  insanity,  to  the  coma  of  alcohol ;  where  the  late 
Bathurst  Woodman  found  a  temperature  of  90''  compatible 
with  recovery,  in  several  instances  at  the  London  Hospital. 
It  may  be  brought  about  from  diarrhoea,  vomiting,  or 
haemorrhage ;  and  consists  of  a  sharp  fall  below  the  normal, 
there  often  being  something  of  a  rise  after  the  sharp  fall.  At 
other  times  the  collapse  occurs  during  a  pyrexial  condition,  as 
seen  in  the  accompanying  diagram.* 

Such  a  sudden  fall  in  enteric  fever  would  indicate  hsemor- 
rhage  in  the  bowel.     A  sharp  fall  may  follow  the  cold  bath. 


1 

■ 

1 

■ 

»■ 

1 

■ 

!■ 

B 

B 

SB 

■■ 

The  ingestion  of  cold  fluids  will  lower  the  temperature  a\ 
degree  or  two  for  a  brief  time. 

Now  in  estimating  the  significance  of  a  subnormal  tem- 
perature the  circumstances  have  to  be  considered.  In 
diseases  of  inanition  the  temperature  falls,  and  the  danger 
lies  in  its  falling  below  the  point  compatible  with  life. 
Then  in  acute  collapse  there  is  danger  in  proportion  to  the 

*Allthe  charts  not  otherwise  indicated  are  taken  from  Wanderlich's 
work  ;  translated  by  the  New  Sydenham  Society,  and  I  have  to 
thank  the  Honorary  Secretary,  Mr.  Jonathan  Hutchinson,  for  his 
permission  to  make  use  of  them. 


THE  TEMPERATURE.  165 

amount  of  fall,  and  the  circumstances  attending  it.  One 
matter,  to  my  mind,  too  little  attended  to  in  narcotic  poison- 
ing, is  the  fall  of  temperature  produced  by  the  palsying 
effect  of  the  toxic  agent  upon  the  respiration  and  the  circu- 
lation, diminishing  the  chemical  interchanges.  The  effect  of 
the  drug  is  intensified  by  the  lowering  of  the  temperature  ; 
until  a  point  is  reached  when  the  palsied  centres  cease  to 
act  altogether. 

There  are  times  when  one  fears  collapse  in  disease,  and 
finds  a  crumb  of  comfort  in  the  temperature  keeping  high. 

*  Well,  the  temperature  keeps  up,'  is  the  remark  not  un- 
commonly heard.  A  fall  coming  on  in  a  person  whose 
powers  are  weakened  is  j  ustly  dreaded,  especially  in  thoracic 
disease. 

Pyrexia. — Eises  of  temperature  are  far  more  frequently 
met  with  than  subnormal  temperatures  ;  at  least  in  circum- 
stances where  the  thermometer  is  an  important  witness. 
All  febrile  affections,  all  inflammatory  affections,  entail  a 
rise  of  temperature.  '  A  temperature,  therefore,  below  the 
maximum  of  healthy  variation  is  sufficient  to  exclude  all 
febrile  and  acute  inflammatory  diseases.' — (Flint.)  Tetanus 
involving  great  muscular  action  entails  a  high  temperature, 
even  over  110°  at  times.  Rheumatic  fever  is  liable  to  give 
rise  to  hyperpyrexia,  running  up  from  106°  to  111°.  Scar- 
latina and  relapsing,  or  famine  fever,  both  give  high  tempera- 
tures ;  the  first  not  uncommonly  reaches  104°  or  105°,  while 
the  latter  may  touch  107°,  yet  death  from  relapsing  fever  is 
not  particularly  common.     A  steady  upward   rise  from  a 

*  high '  to  a  '  very  high '  temperature  cannot  be  regarded 
without  grave  anxiety.  A  point  to  be  noticed,  a  matter 
most  marked,  and  yet  one  for  which  no  satisfactory  ex- 
planation has  yet  been  tendered,  is  '  the  morning  fall,'  with 
'  the  evening  rise.'  This  diurnal  oscillation  is  more  or  less 
pronounced  in  all  cases ;  in  some  it  is  very  marked,  as  in 
softening  tubercle,  for  instance;  while  in  the  varioloid 
tracing  the  difference  is   comparatively  slight.     Sometimes 


1 66 


PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


the  temperature  rises  up  to  death,  as  in  the  case  of  fatal 
small-pox  given  further  on.  In  phthisis  'it  is  seldom 
death  occurs  with  a  persistently  rising  temperature,  in 
immediate  sequence  to  the  previous  fever.' — (Wunderlich.) 


In  acute  specific  pyrexia  the  temperature  not  unfrequently 
rises  till  death  arrests  it.  The  following  tracings  indicate 
the  rise  of  pyrexia.  The  first  gives  a  gradual  rise,  as  is  met 
with  in  many  conditions  of  moderately  acute  pyrexia.  The 
second  gives  the  sharp  rise  of  ague.  This  might  also 
stand  for  the  quick  rise  of  acute  indigestion.  While  the 
third  gives  a  pyrexia  shooting  up  into  a  hyperpyrexia, 
where  a  serious  condition  is  passing  into  one  of  imminent 
danger  to  life.*  There  is  tben  a  gradual  rise,  and  a  sharp 
rise. 

In  the  same  way  defervescence  comes  about:  there  is  the 
gradual  fall  (lysis)  seen  in  the  first  tracing,  while  the  rapid 
fall  (crisis)  is  depicted  in  the  second.  The  third  tracing 
represents  the  pyrexial  curve  of  an  ordinary  febrile  con- 
dition as  one  of  the  exanthems,  for  instance  (though  each 
has   its   own   temperature   outline,   as    seen   further    on) ; 

*  The  rise  may  continue  for  some  time  after  death,  as  in  yellow- 
fever,  where  a  temperature  of  110^  is  not  uncommon  an  hour  or  two 
after  death. 


THE  TEMPERATURE. 


167 


while   in   enteric  fever   the  curve  is  extended    over   four 
times  as  long  a  period.     It  is  well  to  familiarise  the  eye 


in4. 

A 

" 

IUt 

103 

! 

102 

101°! 

0 

\r\r\ 

/ 

\/ 

A 

/ 

iV 

v\a 

\ 

V 

\^ 

\ . 

V 

V 

Y 

100 

QQ 

\ 

yy 

••• 

... 

... 

... 

... 

... 

>•• 

V 

v^, 

■ 

\,       : 

102 
101° 

S-: 

inpi 

1; 

100 

99  .  , 

,       1 -••■••:■ 

... 

••• 

TTV+r 

with  typical  tracings,  as  by  so  doing  any  deviation  there- 
from is  all  the  more  readily  marked.     Of  course  cases  vary, 


i.e.,  present  individual  variations ;  still  there  are  broad 
rules  worth  rememberino-.  Wunderlich  gives  some  in  these 
words  : 

'  In  small-pox  the  fastigium  (the  pyrexial  rise)  ends  as 
soon  as  the  eruption  becomes  "  shotty."  In  measles  it 
terminates  when  the  eruption  is  at  its  height.  In  scarla- 
tina when  the  exanthem  begins  to  pale.  In  pneumonia 
when  the  hepatization  is  completed,  seldom  before  the  third, 
or  after  the  ninth  day.  In  true  petechial  typhus  towards 
the  end  of  the  second  week,  sometimes  in  the  middle  of  the 
third   week.     In   abdominal   typhus,  or   enteric   fever,  in 


i6S         PHYSIOLOGICAL  FACTOR  IN  DIAC^^OSIS. 

mild  cases  in  the  middle  or  at  the  end  of  the  second  week  ; 
in  severe  cases  in  the  middle  or  at  the  end  of  the  third 
week,  and  sometimes  not  till  the  fourth  week.  In  influ- 
enza it  generally  ends  after  a  few  days.  In  parenchy- 
matous tonsillar  angina  after  lasting  from  three  to  seven 
days.' 

Before  proceeding  to  give  some  more  special  temperature 
curves,  a  few  words  may  be  said  as  to  some  points  to  be 
observed  in  medical  thermometry,  which  may  prevent  an 
erroneous  reading  of  the  thermoraetrical  observations. 
And  the  following  observation  by  Wunderlich  is  worthy  of 
careful  thought : 

'  When  one  studies  the  rules  which  may  be  deduced 
from  the  comparison  of  separate  cases,  one  never  feels  quite 
satisfied,  although  they  may  be  derived  from  one^s  own 
extended  experience.  These  rules,  however  cautiously 
they  may  be  drawn  from  a  great  number  of  separate 
observations,  are  never  complete,  exhaustive,  or  exact 
expressions  of  the  facts.  All  the  faults  of  empirical  ab- 
stractions are  common  to  them ;  they  fail  to  bear  the 
stamp  of  inevitability,  and  fresh  experiences  of  another 
kind  may  probably  modify,  and  possibly  overthrow  them.' 

The  temperature  will  show  individuality  in  most  cases ; 
just  as  each  case  has  its  own  features  in  other  respects. 
Consequently  typical  temperature-curves  can  never  be 
more  than  at  least  partly  schematic.  Wunderlich  sees  this, 
for  he  states  :  '  In  order  to  extract  the  general  facts  from 
separate  observations,  we  must  look  less  to  the  numbers 
than  the  form,  that  is,  to  the  varied  outline  of  the  wave- 
systems,  which  each  separate  curve  furnishes  us.  Only  in 
this  way  are  we  able  to  construct  a  sort  of  model  curve, 
which  may  approximatively  express  the  peculiarities  of  single 
cases.'  The  reader,  then,  must  study  the  general  outline  of 
the  different  curves  of  various  pyrexiae,  as  part  of  the 
natural  history  of  the  disease.  And  here  the  reader  must 
excuse   an  interpolation.     In  the  writer's  experience,  the 


r 


THE  TEMPERATURE.  169 

clearest-headed  practitioners  have  been  those  who  studied 
disease  as  a  naturalist  studies  a  group  of  plants  or  animals ; 
and  then  a  species,  with  its  variations.  So  in  medicine 
there  are  groups  of  diseases  like  malnutrition  in  its 
various  forms,  and  pyrexia,  for  instance  ;  and  the  first  step 
is  to  get  up  the  outlines  of  each  group;  next,  the  features 
of  each  malady ;  after  which  the  individual  peculiarities 
are  easily  recognised.  The  study  of  the  natural  history  of 
a  disease  includes  its  temperature  curve,  if  it  has  one. 
Familiarity  with  the  outline  of  the  disease  will  enable  the 
detection  of  any  singularity  to  be  readily  made  ;  and  what 
is  more,  makes  its  explanation  readily  apparent,  at  least  in 
most  cases. 

Then,  again,  there  are  associations  of  temperature-varia- 
tions to  be  taken  into  account,  and  ranged  aloncjside  the 
evidence  of  the  thermometer.  Thus,  as  Senator  points  out, 
there  can  be  no  evaporation  of  water  demonstrated  in  rising 
fever.  While  in  defervescence  there  is  well-marked  per- 
spiration and  exhalation  of  water,  by  which  the  heat-loss 
is  made  very  considerable.  Consequently,  if  the  tempera- 
ture show  a  fall  (and  this  is  not  due  to  an  imperfect  obser- 
vation, for  that  is  always  the  point  to  be  sure  about  when 
the  temperature  is  below  what  might  be  anticipated)  in  a 
pyrexial  case,  and  there  be  no  perspiration,  the  question  arises 
at  once,  Is  this  '  defervescence  ?'  or  is  there  something  else  in 
action  ?  In  other  words,  the  instrument  must  be  wielded 
intelligently,  like  the  stethoscope.  Some  men  hear  something 
distinctly,  but  what  its  pathological  correlative  is  they 
cannot  tell ;  the  same  men  look  at  the  index  of  their  ther- 
mometer in  a  vague  way,  and  either  can  form  no  conclusion 
therefrom,  or  jump  to  some  conclusion  by  no  means  neces- 
sarily a  correct  one.  Some  men  are  always  making  observa- 
tions :  but  they  never  make  deductions  at  all  commensurate 
with  their  observations,  either  as  to  the  case  in  connection 
with  which  they  are  made ;  or  anything  else.  It  is  easy  to 
make  an  observation  with  an  instrument  of  precision,  but 


I70  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

individual  thought,  the  sweat  of  the  brow,  is  indispensable 
to  correct  interpretation  of  it  when  made. 

Whenever  there  is  a  high  temperature  steadily  main- 
tained, there  will  be  found  either  a  febrile  condition  with 
its  own  features  and  complications ;  or  a  local  cause  with  its 
special  characteristics — at  least,  as  a  general  rule.  In 
women  there  are,  however,  '  hysterical  temperatures ;'  or 
there  are  pyrexial  storms  corresponding  to  the  catamenial 
periods,  if  carefully  hunted  out.  In  one  case  a  sharp 
pyrexia  came  on  in  a  lady  a  month  after  her  confinement, 
and  ran  on  to  the  production  of  the  typhoid  condition; 
without  any  apparent  cause.  When  pressed  to  give  it  a 
name,  the  old  expression,  '  nervous  fever,'  was  aU  that 
could  be  said.  The  patient  recovered  under  anti-pyretic 
measures,  but  at  the  end  of  three  weeks  the  temperature 
rose  again.  On  careful  examination,  it  was  found  these 
'  pyrexial  storms '  corresponded  to  the  times  of  the  cata- 
menial weeks;  had  impregnation  not  occurred.  The  careful 
practitioner,  when  puzzled  with  a  pyrexia  in  a  woman 
during  the  child-bearing  period,  should  never  forget  the 
catamenial  week  of  the  raensual  cycle  ;  this  may  not  only 
prevent  his  making  a  blunder,  but  may  secure  him  no  little 
credit. 

Thermometrical  observations  are  not  free  from  sources  of 
fallacy,  and  may  mislead  unless  these  observations  are  cor- 
rected by  other  observations.  The  finer  the  instrument  of 
precision,  the  more  knowledge  is  requisite  to  wield  it  wisely; 
and  the  wider  the  diagnostic  grasp,  the  more  valuable  will 
each  precise  observation  become.  Clinical  observations  are 
to  be  read  as  Opie  mixed  his  colours — '  with  brains,  sir  !' 
For  instance,  there  exists  a  consolidation  of  a  lung-apex, 
with  a  moist  rale  in  the  middle  of  it ;  this  may  be  a  local 
bronchial  rale,  or  it  may  indicate  softening.  The  evening 
temperature  will  commonly  decide  the  question :  and  a  very 
important  matter  this  often  is.  Again,  the  thermometer 
will  tell  of  rising   pyrexia,  even   despite   energetic,    wise 


THE  TEMPERATURE. 


171 


treatment ;  and  its  voice  is  then  that  of  a  prophet,  albeit  a 
prophet  of  evil.  At  other  times,  it  is  the  herald  of  good 
news — of  commencing  defervescence.  The  clinical  thermo- 
meter and  the  watch  are  instruments  of  precision  of  price- 


Fak'\C     f  \  2 
IOS-s\l^l  ' — — 


/o^-o\^o 


tOO-kr    58 


WS-  8    4/  — 


/04-0   40 


W02-t  39 


Mild  Scarlatina. 


Measled. 


less   value ;    yet,    be   it    remembered,   it    is    physiological 
disturbance  which  gives  them  their  value  I 

Having  thoroughly  comprehended  what  has  been  written 
about   temperature-curves — viz.,  that  a  typical  curve  can 


W5-S 

IOi-2 
WO-k 
9S-6 

c 

f 

2 

3    A- 

5 . 

6 

UO 
39 

38  \ 
31 

fj 

A 

i 

H 

[\ 

( 

\ 

1 

5 

/ 

^? 

^ 

/ 

Fah* 
109- A 

101-6 

lOS-  8 

IOl^•0 

lOh  2 
m  A 

C 

2 

J    4    5 

6 

7 

% 

9 

W     11 

43 
1^9 

\ 

LI 

1-' 
40 

^ 

% 

A 

r 

1 1 

I 

39 

38 

T 

^ 

H\ 

Varioloid. 


Fatal  Small-pox. 


only  possess  a  general  outline — it  may  be  well  to  consider 
the  temperature-curve  of  some  common  maladies.  For 
instance,  compare  the  curve  of  ordinary  scarlatina  with  that 
of  measles.      The  highest   point   is  reached  early  in   the 


172         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


pyrexia  in  scarlatina,  while  in  measles  it  comes  just  before 
the  defervescence. 

Then  the  curve  of  varioloid  contrasts  with  the  tracing 
of  small-pox,  terminating  fatally  with  a  sharp  pj^rexial 
rise. 

Then,  again,  the  long  curve  of  a  typical  ordinary  case 
of  enteric  fever  presents  a  character  quite  unlike  the  tracings 


Exiteric  Fever. 

of  the  temperature  in  relapsing,  or  famine  fever.  The  one 
is  a  long,  flat  curve,  while  the  other  has  a  broken,  crag-like 
outline. 


Fah'\  C     2 


8\  9\/0    //    /P    /J   /4    fS    A!- 1  /7    /S  I  /5    20    2/ 


Qe-slsel- 


Kelapsing  Fever. 


THE  TEMPERATURE. 


173 


Relapsing  fever  is  a  sharp,  sudden  pyrexia.  Still,  when 
a  relapse  occurs  in  case  of  typhoid  fever,  the  curve  of  the 
relapse  is  so  much  like  that  of  relapsing  fever,  that  it  is  un- 
necessary to  give  it  here. 


W5-S 
WU-0 
102-i 
100 -Iv 
98- e 

C 
Al 

UO 

39 

38 

37 

3 

4 

s 

6 

7 

8 

9 

7 

\/ 

i_ 

■ 

A 

^ 

I 

r 

L 

^ 

J 

t 

- 

V 

Erysipelas. 

Of  like  character  as  brief  but  sharp  pyrexia  is  the 
tracing  of  erysipelas,  contrasting  with  the  curve  of  severe 
typhus  fever. 


Fa/i  ' 

.01.6 
If)/,  n 

C 
/  /I 

5 

4-     5 

6 

7 

8 

9 

W 

II     12 

/3    /4 

/5 

/<J 

/7 

/s 

19 

25 

2/ 

A 

A 

[ 

\ 

ht- 

A^ 

\ 

M 

/ 

y 

V 

/ 

\ 

Jy 

V 

V^ 

7 

i^ 

lOO-h 

40 

39 

M 

V 

^ 

1 

1 

4 

38 



— f 

" 

n 

A 



37j 

] 
1 

i, 

1 

1 



1 

\ 

Typhus. 

The  curves  of  typhus  and  of  enteric,  or  typhoid  fever  tell 
of  an  illness  which  involves  a  considerable  time ;  though  in 
some  cases  the  fever  is  cut  short,  or  in  other  words  '  aborts ;' 
and  then  the  tracing  approaches  the  short  curve  given  at 
p.  167. 


174 


PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


Typical  uncomplicated  pneumonia  gives  something  of  this 
kind  : 


Pneumonia. 


Pysemia  gives  a  tracing  much  as  follows.  Of  course,  cases 
dififer;  but  pysemia,  as  ordinarily  seen,  gives  a  comparatively 
low  pyrexial  temperature,  as  a  rule,  with  sharp  rises  corre- 
sponding to  rigors. 


'Fall  C     1      2'    3     4     5     6      T 

■If)  "T'C    /  1 i-i 1 ■ 

"s 

■9 

10 

11 

12 

lOvO  ^"          1  \                 A        11 

\ 

102-2  39       1                    J       \l          I 

/ 1!  _lI 

V 

\ 

WO-hf  38     ,                                           / 
9n-6  57  1                iV                                I 

A 

-^ 

y 

Pyaemia  with  Rigors. 


The  next  tracing  is  that  of  the  late  French  statesman, 
M.  L^on  Gambetta.  His  wound-temperature  never  rose 
over  101°,  and  the  tracing,  given  here,  commences  vsdth  the 
sharp  rise,  which  accompanied  the  development  of  the 
abscess  at  the  ilio-coecal  valve,  which  revealed  itself  after 
his  wound  in  the  wrist  had  healed  and  he  had  been  out 


THE  TEMPERATURE. 


175 


of    doors   again.      The   falls   correspond   to   full   doses   of 
quinine. 


Gambetta's  tracing. 

The  following  tracing  was  taken  by  Mr.  "Waller,  from  an 
empyema  with  pus  discharging  through  the  lung,  at 
Victoria  Park  Hospital, 


Empyema. 

The  following  two  tracings  were  taken  from  two  cases 
in  my  wards  at  Victoria  Park  Hospital.  They  both  indi- 
cate softening  tubercle :  the  upper  one  is  from  a  case  where 
the  result  is  doubtful;  but  from  the  family  history  it  is  pro- 
bable the  case  will  ultimately  succumb.  While  the  latter 
is  taken  from  a  case  with  the  worst  prognosis ;  but  which 
made  a  temporary   rally,   under   treatment,   and   left   the 


176         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


hospital,  without  furnishing  an  opportunity  of  seeing  the 
actual  condition  of  the  lunof. 


Softening  Tubercle. 


(Softening  Tubercle. 

With  these  the  reader  may  contrast  a  tracing  of  galloping 
consumption — acute  miliary  tuberculosis. 

The  concluding  tracings  are  those  of  the  different  forms 
of  intermittent  fever  :  quotidian,  tertian,  and  quartan. 


Quotidian  (Ague) 


Tertian  (Ague). 


THE  TEJIIPERATURE. 


^77 


In  placing  these  temperature  tracings  before  tlie  reader, 
the  writer  disclaims  anything  pretending  to  a  comprehensive 


Quartan  (Ague). 

handling  of  the  matter  of  temperature-fluctuations,  Wliat 
is  given  here  is  merely  a  bird's-eye  view  of  the  subject ;  with 
some  of  the  prominent  points  thrown  up  in  outline.  Nothing 
more  !  The  subject  is  yet  only  in  its  infancy  ;  and  every 
observer  will  have  to  trust  largel}^  to  his  own  experience. 
But  what  has  been  placed  before  him  here  may  be  a  guide 
to  him  in  casting  his  experience  into  some  permanent  con- 
crete shape.  It  will  help  him  (it  is  hoped)  to  systematise 
his  observations  ;  at  least  to  some  extent.  If  he  be  familiar 
with  the  work  of  Wunderlich,  he  wnll  gain  little  from  this 
chapter.  But  for  the  bulk  of  practitioners  this  chapter  will 
be  as  instructive  as  any  other  in  the  treatise,  whatever  its 
value  may  be ! 

The  subject  of  thermometry  must  not  be  made  to  stand 
alone  from  other  functional  disturbances  of  the  bod}',  as  the 
respiration  and  the  circulation  ;  nor  yet  to  be  held  out  of 
proportion  to  these  equally  important  matters.  If  the  young 
practitioner  will  study  the  three  together,  compare  them, 
and  note  their  parallelism,  or  the  want  of  it,  in  various 
maladies,  he  will  come,  as  Dr.  Campbell  and  others  have,  to 
see  that  when  observations  of  two  of  the  three  have  been 
taken,   the  third   can   usuall}^  be   fairly   calculated.      Time 

12 


178  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

becomes  an  object  as  practice  increases,  and  the  systematic 
use  of  watch  and  thermometer  together  would  soon  teach 
the  lesson  of  when  the  latter  may  be  dispensed  with ;  and, 
what  is  even  more,  when  a  thermometrical  observation  is 
urgently  required.  This  systematised  use  of  instruments  of 
precision  would  be  far  more  valuable  to  patient  and  prac- 
titioner alike,  than  a  random  resort  to  the  thermometer,  and 
a  guess  at  the  meaning  of  what  it  records. 

The  accompanying  diagram  is  taken  from  a  portion  of  a 
case  of  enteric  fever,  in  which  Wunderlich  had  the  tempera- 
ture, the  pulse,  and  the  respiration  all  carefully  taken.     The 


portion  here  given  represents  a  somewhat  sharp  pyrexial 
rise  occurring  in  the  course  of  a  mild  case  of  tj^phoid  or 
enteric  fever.  It  will  serve  the  purpose  of  demonstrating 
that  there  is  a  general  parallelism  betwixt  the  three.  The 
thermometer,  however,  gives  a  more  broken  outline  than  the 
other  two.  Still,  there  is  enough  of  resemblance  to  justify 
what  has  just  been  stated,  that  when  two  out  of  the  three 
factors  are  taken,  the  third  can  usually  be  fairly  calculated. 
Nothing  more  is  claimed  than  that  a  busy  man,  who  has 
carefully  observed  when  he  had  the  time,  may  often  tell  ia 
later  days  when  he  may  fairly  dispense  with  a  thermometri- 


THE  TEMPERATURE.  179 

cal  observation,  as,  also,  when  it  is  desirable  to  take  one : 
when  he  has  no  longer  time  to  spare. 

The  practical  utility,  to  my  mind,  of  familiarising  the  eye 
with  the  various  curves  of  different  pyrexial  maladies 
commonly  encountered  in  practice,  lies  mainly  in  this  : 

If  familiar  with  the  typical  curve  of  the  malady  before 
him,  the  practitioner  is  at  once  on  the  alert  if  the  ther- 
mometer indicates  any  modification  or  variation  therefrom : 
he  at  once  looks  out  for  the  cause.  If  he  had  no  preconceived, 
opinion  on  the  subject,  for  anything  he  can  know,  the 
modification  may  be  quite  normal,  i.e.  so  far  as  a  pathologi- 
cal condition  has  a  norm.  The  study  of  the  natural 
history  of  disease  is,  however,  making  great  strides  towards 
the  establishment  of  such  norms,  which,  making  proper 
allowances  of  individualities  in  each  case,  may  be  accepted 
for  practical  work.  Each  disease  has  its  features,  as  each 
race  of  men  have  their  characteristics,  as  the  European 
differs  from  the  Mongol.  While  European  races  have 
certain  distinguishing  features,  as  the  Latin,  the  Teuton,  and 
the  Sclav,  who  differ  from  the  Hun  (who  is  a  Mongol).  We 
can  at  once  distinguish  a  typical  German  from  an  Italian ; 
and  so  it  is,  or  perhaps  rather  ought  to  be  with  disease  and 
its  differentiation,  viz.,  that  each  possesses  its  own  tempera- 
ture curves,  just  as  much  as  any  other  feature  it  may  possess. 
It  is  by  such  grouping  of  phenomena  we  distinguish  one 
from  another  ;  and  in  this  grouping  the  pyrexial  curve  is  an 
important  factor. 


12—2 


CHAPTER  X. 

MOTOR  AND   SENSORY   DISORDERS. 

[Ix  this  chapter  the  text-book  of  Dr.  James  Ross,  '  The 
Diseases  of  the  Nervous  System/  is  followed,  being  the 
most  recent  and  complete.  As  much  condensation,  -with 
extracts,  is  necessary,  this  chapter  has  been  submitted  to 
Dr.  Ross,  in  order  that  he  might  supervise  it;  which  he  has 
kindly  done.  All  quotations  not  marked  otherwise  are 
taken  from  his  book.] 

The  brain  being  enclosed  in  a  firm  bony  case,  it  is  all  but 
impossible  to  examine  it  physically,  as  we  can  the  thorax ; 
consequently  we  trust  to  physiological  indications,  of  which 
the  nervous  system  admirably  admits  by  its  function.  From 
modifications  of  motion  and  sensation  we  learn  much  as  to 
the  area  of  the  brain  which  is  the  seat  of  disease,  i.e.,  if  the 
disease  be  central.  The  observations  of  Fritsch  and  Hitzicr, 
carried  out  and  amplified  by  Ferrier,  have  mapped  out  the 
cerebral  hemispheres  into  areas,  which  were  before  a  terra 
incognita  simply — Marshall  Hall  ascending  to  the  medulla 
oblongata,  but  no  further.  Now  we  know  that  there  is  an 
anterior  perceptive  area;  a  central  motor  band;  and  posterior 
lobes,  which  are  related  to  the  viscera  and  our  subjective 
sensatories.  (The  recent  discoveries  of  scientific  observers 
show  how  wonderfully  the  observations  of  Gall  and 
Spurzheim  approached  the  facts — there  being  a  clear,  if  only 
broad,  resemblance  betwixt  their  views  and  those  of  recent 
observers.      The   comparison    is   about   this :  the   pbreno- 


M O  TOR  A ND  SENSOR  V  DISORDERS.  1 8  r 

logical  map  is  to  the  real  map  like  the  fantastic  shapes  in 
shadowy  outline  seen  in  fog,  of  a  mass  of  mountain  with 
crag  and  ravine,  grassy  slopes  and  tumbling  rivulets,  when 
clearly  seen.  The  highly  localised  differentiations  of  the 
phrenologists  brought  the  whole  scheme  into  disrepute.) 

An  injury  to  the  cortex  of  the  brain  will  give  a  corre- 
sponding disturbance  by  which  it  can  be  recognised  if  it 
occur  in  either  the  motor  or  sensory  area ;  but  not,  in  the 
present  state  of  our  knowledge,  if  located  elsewhere.  [Of 
coui'se,  the  modern  student  is  familiar  with  recent  brain - 
investigations,  while  older  men  pei'haps  are  not.  If,  there- 
fore, any  of  the  first  feel  insulted  by  my  generalisations 
here,  they  will  perhaps  accept  the  explanation  just  given,  in 
extenuation  of  my  offence.]  A.  loss,  more  or  less  complete, 
of  motion  or  sensation,  or  an  abnormal  form  of  either,  will 
result  from  an  injury,  or  morbid  change  in  the  corresponding 
cortical  area  of  the  cerebral  hemispheres.  But  the  modi- 
fication may  be  due  to  some  change  at  the  periphery,  or  to 
something  affecting  the  nerve-fibrils  in  their  course,  and 
consequently  not  be  central.  For  instance,  the  facial  nerve 
is  apt  to  be  paralysed  (Bell's  paralysis).  It  may  be  para- 
lysed on  one  side,  at  other  times  on  both.  This  may  be 
due  to  central  causes,  and  be  a  part  of  an  extended  cerebral 
lesion.  Or  it  may  be  due  to  pressure  on  the  nerve  tract  in 
the  bony  channel  in  which  it  runs;  or  from  the  many  organs 
liable  to  morbid  growth  near  which  it  passes.  Or  it  may 
be  purely  superficial,  from  exposure  to  cold :  the  rheumatic 
paralysis,  'probably  due  to  a  slight  neuritis,  followed  by 
serous  or  plastic  exudation  into  the  sheath  of  the  nerves, 
which  compresses  the  nerve  fibrils.'  And  what  is  found  in 
the  seventh  facial  nerve  may  occur  with  any  other  nerve. 

Then  the  oncome  of  this  special-nerve,  or  individual 
paralysis  may  have  various  relations,  which  throw  light 
upon  its  significance.  '  The  onset  of  facial  paralysis  differs 
according  to  its  cause.  It  appears  suddenly  when  it  results 
from  traumatic  lesion  of  the  nerve  ;  and  when  it  is  caused 


i82         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

by  exposure  to  cold,  the  patient  is  usually  surprised  to  find 
one  side  of  his  face  paralysed  in  the  morning.  When 
paralysis  results  from  disease  which  invades  the  nerve 
secondarily,  either  by  gradual  compression  or  by  altering 
its  texture,  the  paralytic  symptoms  become  slowly  and 
gradually  developed,  and  spread  from  branch  to  branch  of 
the  nerve.  Premonitory  symptoms  may  be  experienced  for 
some  days  before  the  appearance  of  the  paralysis ;  these 
consist  of  pain  on  the  side  of  the  face  which  is  subsequently 
paralysed,  noises  in  the  ear,  deafness,  and  abnormal  sensa- 
tions of  taste  on  the  same  side.'  In  the  latter  case,  there 
are  evidences  given  of  coming  mischief,  which  are  absent 
when  the  paralysis  is  traumatic  or  rheumatic ;  or  when  it  is 
part  of  a  wider  injury  from  apoplexy,  embolism,  or  efi'usion. 
The  paralysed  side  is  smooth,  un wrinkled,  and  expres- 
sionless. The  patient  cannot  close  the  eyelid ;  if  Horner's 
muscle  be  involved,  the  tears  run  down  the  cheek  instead 
of  into  the  lachrymal  canal  ;  the  buccinator  muscle 
flaps  like  a  loose  sail  in  speaking  or  in  any  expiratory 
action;  the  saliva  dribbles  down  the  palsied  side,  which 
falls  to  a  lower  level  than  the  sound  side.  At  the  same 
time  the  sense  of  hearing  may  be  preternaturally  acute. 

The  observation  of  a  mere  paralysis,  no  matter  whether 
highly  localised  or  extensive,  is  in  itself  insufficient  to  throw 
much  light  on  a  case  without  investigation  as  to  the  cause 
of  the  said  paralysis ;  which  latter  involves  both  further 
observation  and  reflection.  It  may  not  be  nervous  at  all, 
but  be  due  to  other  causes.  Loss  of  motor  power  in  a  limb 
may  be  due  to  osseous  changes  which  prevent  motion,  or 
less  commonly  to  wasting  of  muscles.  Make  sure,  then,  first 
that  it  is  nervous  in  its  causation ;  then  see  if  there  is  any 
cause  connected  with  the  nerve-trunk.  Hughlings  Jackson 
says  it  is  not  uncommon  to  find  a  patient  at  the  London 
Hospital  who  has  '  lost  the  use  of  his  arm,'  having  fallen 
asleep  with  the  arm  over  a  chair — when  drunk,  of  course. 
Then,  if  it  be  probably  central,  see  what  its  relations  are. 


MOTOR  AND  SENSORY  DISORDERS.  1S3 

A  girl  with  chorea  is  often  described  by  her  mother  as 
having  '  lost  the  use  of  her  arm,'  there  being  actually  a 
considerable  loss  of  power. 

Lessened    Motor   Power. — Diminution,   or  loss   of  motor 
power  from  central  causes  has  highly  interesting  relations. 
Hemiplegia  may  result  from  rupture  of  an  artery  ploughing 
up  one  or  other  hemisphere.     If  on  the  left  side,  there  is 
impairment    of    speech    from    Broca's    convolution   being 
injured  or  compressed.     This  is  a  common  form  of  paralysis, 
*  right    side    paralysis   with   impaired   speech.'     Here   the 
speech  is  affected  by  the  muscles  of  the  mouth,  etc.,  being 
paralysed  from  an  injury  to  their  motor  centres;  the  motor 
centres  for  the  muscles  of  articulation  and  those  by  means 
of  which  the  special  movements  of  the  hand  are  executed 
being  regionally  near   each    other.     When  Broca's   convo- 
lution is  implicated,  then  another  phenomenon  is  mani- 
fested; the  patient  becomes  aphasic,  that  is,  he  cannot  find  the 
word  he  desires,  and  either  fails  to  find  the  word,  or  a  word, 
or  more  commonly  uses  a  wrong  word.  This  is  quite  distinct 
from  impaired  articulation  due  to  paralysis  of  the  muscles 
involved  in  speech,  from  injury  to  their  cerebral  centres. 
Inability  to  find  the  word  he  wants  is  '  amnesic  aphasia ;' 
and  the  lesion  is  in  the  angular  gyrus  and  superior  tempero- 
sphenoidal  convolution.     Inability  to  articulate  the  word — 
to  give  outward  expression  to  intellectual  states  by  words 
written  or  spoken,  or  by  pantomime,  is  complete  ataxic 
aphasia,  and   the    lesion   is   in   Broca^s   convolution.      To 
those  who  feel  curious  on  this  matter.  Dr.  Ross's  book  will 
give  them  much  highly  interesting  information.     A  man 
may  be  '  speechless '  but  not  '  wordless ;'  he  may  be  unable 
to    find    the    woi'd    he    wishes    (amnesic    aphasia),   or   uses 
a  wrong  word  having  an   association   of   idea,   as   '  worm 
powder '  for  '  cough  medicine,'  or  an   association  of  sound, 
as  *  parasol '  for  '  castor  oil '  (Hughlings  Jackson).     Where 
the  word-centre,  located  in  Broca's  convolution,  is  involved, 
the   power    of  articulation   is   affected ;   which    commonly 


lS4  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

occurs  when  tlie  motor  centres  near  the  fissure  of  Rolando 
are  the  seat,  or  part  of  the  seat  of  the  lesion.  (Tt  is 
impossible,  however,  here  to  follow  out  the  subject  of  the 
precise  cerebral  lesion  which  occurs  with  the  different 
paralyses.  Those  who  have  been  privileged  to  witness 
Dr.  Ferrier's  observations  know  how  entrancing  they  were 
and  are,  and  how  accurate  they  are  also ;  but  the  matter 
cannot  be  discussed  here.  The  allu.sions  must  be  of  a 
general  character.) 

The  first  point  to  notice  is  any  loss  of  expression  about 
the  face — any  smoothing  out  of  wrinkles,  any  obliteration  of 
furrows,  any  muffling  of  the  speech.  Then  follows  'ptosis,' 
that  is,  a  falling  of  the  eyelid.  Its  interest  lies  in  the  fact 
that  the  eyelid  is  supplied  by  a  branch  of  the  third  nerve. 
The  opposite  condition  of  inability  to  close  the  eye  is 
linked  with  paralysis  of  the  seventh  nerve. 

Then  'strabismus'  maybe  'convergent'  or  'divergent,' 
according:  as  the  external  or  internal  rectus  muscle  is 
affected.  A  squint  when  permanent  has  no  significance  ; 
when  a  person  is  observed  to  begin  to  squint  at  intervals,  then 
serious  brain-mischief  is  probably  going  on  ;  when  a  child 
is  noticed  to  squint  at  times,  this  is  of  the  worst  omen,  as  in- 
dicating in  all  probability  tubercular  meningitis  ('  water  on 
the  head ').  It  may,  however,  be  due  to  the  irritation  of 
teething.  As  with  other  nerves,  the  cause  of  the  impaired 
motion  may  be  a  purely  local  one,  as  cold,  pressure  on  the 
nerve-trunk  in  its  curve  ;  or  be  a  central  lesion  ;  or  be 
reflex.  Injuries,  growths,  osseous,  syphilitic,  or  other,  extra- 
vasations of  blood,  or  other  fluid,  are  the  common  causes  of 
disturbance  of  the  ocular  muscles;  while  diphtheria  may 
leave  behind  all  sorts  of  forms  of  paralysis. 

The  pupil  is  affected  by  various  conditions  about  which  it 
is  not  possible  to  write  precisely.  Some  facts  are  generallj^ 
recognised,  as  the  contraction  produced  by  opium,  or  the 
dilatation  produced  by  belladonna ;  and  observation  of  the 
pupils   will  often  give  the  most  valuable  information,  and 


'MOTOR  AND  SENSORY  DISORDERS.  185 

enable  the  medical  man  to  put  a  pertinent  question,  very 
much  to  theS  patient's  surprise.  The  pupils  are  irregular  in 
the  general  [paralysis  of  the  insane.  Then  the  pupil  is 
affected  by  light,  increasing  in  size  at  night  and  decreasing 
in  the  day.  The  mobility  of  the  iris  is  interfered  with  by 
many  and  varying  cerebral  conditions;  consequently  in  con- 
ditions of  coma  and  insensibility  the  conduct  of  the  iris  to 
light  is  often  very  instructive.  Whenever  the  lenticular 
ganglion  is  interfered  with,  then  disturbance  follows  in  the 
muscular  fibres  of  the  iris.  The  behaviour  of  the  pupil  must 
be  taken  into  consideration  along  with  other  phenomena. 
I  wish  it  were  possible  to  lay  down  some  definite  rules  about 
the  indications  given  by  the  behaviour  of  the  pupils ;  but 
as  writers  of  treatises  on  the  nervous  system  and  its  dis- 
eases, have  not  been  able  to  do  this,  it  is  clear  it  is  not  in 
my  power  to  do  it.  Charlton  Bastian  says  :  '  When  the 
condition  of  coma  with  general  paralysis  has  become  estab- 
lished as  the  result  of  an  extensive  lesion  in  the  pons 
varolii  (whether  this  lesion  be  primary  or  secondary)  the 
condition  itself  is  very  apt  to  be  associated  with  contracted 
and  motionless  pupils,  as  in  opium-poisoning,  whereas  in 
cases  of  ventricular  hsemorrhage  the  pupils  are  usually 
dilated.  The  diagnostic  indications  afforded  by  the  con- 
dition of  the  pupils  in  brain  diseases  are  only  too  often 
vague  and  indefinite,  though  the  relations  above  stated,  from 
their  comparative  uniformity,  afford  important  exceptions  to 
this  general  rule.' 

If  this  be  the  opinion  about  the  pupil  in  cerebral  lesions, 
my  experience  with  belladonna,  which  is  by  no  means 
limited,  tells  me  that  the  relations  of  belladonna,  taken  in- 
ternally, to  the  pupil  are  far  too  uncertain  to  be  of  anj- 
practical  value.  Certainly  in  rare  cases  the  pupil  is  dilated, 
and  only  in  rare  cases.  Just  as,  at  times,  a  'pin-point' 
pupil  will  enable  one  to  assert  with  confidence  that  the 
patient  has  been  taking  opium ;  maybe  only  in  a  cough 
lozenge. 


i86         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


1 


Then  the  nose  may  be  drawn  to  the  healthy  side,  while 
the  nostril  of  the  paralysed  side  '  instead  of  expanding  during 
inspiration  falls  in,' 

The  mouth  in  facial  paralysis  is  drawn  to  the  healthy 
side  of  the  face,  '  and  the  distortion  becomes  more  pro- 
nounced during  all  mimetic  movements,  as  in  crying, 
laughing,  and  speaking.'  Sometimes  a  trifling  immobility 
about  one  side  of  the  mouth  will  tell  of  a  sypliilitic  history  ; 
sometimes  the  mouth  is  alone  (apparently)  affected,  and 
there  is  an  impression  abroad  that  such  slight  local  palsy  is 
significant  of  worse  to  come  ;  sometimes  such  impairment  of 
symmetry,  for  it  amounts  to  little  more,  may  tell  of  a  by- 
past  stroke,  while  more  often  the  remaining  lesion  is  some- 
what more  pronounced ;  and  in  other  cases  some  '  drawing 
of  the  mouth  aside '  has  been  occasionally  seen  in  women 
without  anything  further  happening.  It  is  always  well  to 
note  the  features  of  every  patient,  and  if  any  abnormality, 
any  disturbance  of  mobility  be  observed,  to  hunt  it  down, 
and  make  its  relations  clear. 

The  tongue  is  often  seen  to  turn  to  one  side  when  '  put 
out,'  viz.,  the  paralysed  side  ;  the  healthy  side  pushing  the 
other  away.  While  *  the  various  movements  of  the  tongue 
can  only  be  imperfectly  or  not  at  all  performed  on  the 
affected  side.'  Such  is  the  evidence  of  the  tongue  in 
hemiplegia.  '  When  the  paralysis  is  double  and  complete, 
the  tongue  lies  immovable  on  the  floor  of  the  cavity  of  the 
mouth ;  it  is  relaxed,  often  atrophied,  with  its  surface 
v^rinkled,  and  frequently  presenting  slight  fibrillary  con- 
tractions of  its  surface.  If  the  paralysis  is  incomplete,  the 
tongue  can  be  protruded,  but  complicated  movements,  such 
as  raising  the  tip  to  the  roof  of  the  mouth,  or  rolling  the 
tongue  into  a  tubular  form,  are  impossible.'  As  to  the  rela- 
tions of  lingual  palsy,  '  unilateral  paralysis  of  the  tongue  in 
association  with  hemiplegia  indicates  a  cerebral  origin; 
while  bilateral  paralysis  in  connection  with  paralysis  of  the 
lips  and   soft  palate   indicates   a   bulbar   origin.'      Glosso- 


MOTOR  AND  SENSORY  DISORDERS.  1S7 

pharyngeal  paralysis  is  linked  with  mischief  in  the  medulla. 
Lingual  spasm  is  found  with  several  nervous  conditions,  as 
hysterical  convulsions,  chorea,  and  epilepsy ;  while  fibrillary 
contractions  in  the  tongue  occur  in  connection  with  bulbar 
paralysis  with  progressive  muscular  atrophy.  When  the 
tongue  is  implicated  singing  becomes  impossible. 

Linked  with  affections  of  the  tongue  come  affections  of 
speech.  Any  palsy  of  the  tongue  interferes  with  utterance  ; 
but  there  are  also  laryngeal  associations  of  the  voice.  First  in 
prominence  comes  hysterical  aphonia,  a  very  common  affec- 
tion. Some  hysterical  patients  experience  a  difficulty  in 
emptying  the  bladder,  but  here  the  discomfort  usually  soon 
puts  matters  right.  When  '  the  voice  is  lost '  there  is  no 
such  strong  motive  to  correct  the  inability,  and  it  is  allowed 
to  go  on.  Aphonia  in  a  young  woman  often  creates  need- 
less alarm.  (It  may  be  due  to  a  cold  affecting  the  mechan- 
ism of  voice.)  Voice  and  articulation  may  both  be  lost  in 
bulbar  paralysi?.  Loss  of  speech  or  impairment  of  it,  with 
loss  of  memory  for  words,  and  other  matters  of  aphonia,  with 
aphasia  and  amnesia,  cannot  possibly  be  considered  here, 
however  interesting.  For  information  on  details,  the  reader 
can  consult  Dr.  Ross's  book,  or  other  allied  works. 

Hemiplegia. — Paralysis  of  one  side  in  adults  is  usually  due 
to  a  lesion  in  the  cerebral  hemisphere  of  the  opposite  side. 
It  is  seen  mainly  in  the  limbs  of  the  paralysed  side  ;  but  in 
severe  cases  the  inspiratory  muscles  are  implicated  for  the 
first  few  days. 

Frequently  along  with  the  paralysis  there  are  spasms  of 
the  muscles.  They  are  due  to  irritation  set  up  by  inflam- 
matory action  around  the  clot.  They  are  often  detected  by 
passive  movement,  when  not  obvious.  The  extent  of  '  early 
rigidity  '  varies.  Its  onset  may  occur  a  few  days  after  the 
cause  of  the  hemiplegia,  while  usually  it  disappears  soon  ;  but 
it  may  linger.  '  The  appearance  of  early  rigidity  diminishes 
the  patient's  chances  of  recovery,  and  when  it  continues  for 
a  long  time  changes  take  place  in  the  muscles,  tendons,  and 


88         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

joints  of  the  affected  extremities,  which  ultimately  leave 
them  permanently  contracted  and  useless.' 

'  Late  rigidity '  is  due  to  secondary  degeneration,  or 
atrophy  of  the  affected  motor  tracts.  Its  onset  tells  that 
structural  changes  inimical  to  the  recovery  of  functional 
power  are  going  on.  It  is  connected  with  exaggeration  of 
the  reflexes,  as  the  patellar  'tendon-reflex.'  The  attitudes 
taken  by  this  rigidity  vary  considerably  in  different  cases  ; 
'  but  on  the  whole  they  conform  to  the  rule  observed  in 
almost  all  spasmodic  affections,  namely,  that  flexion  pre- 
dominates in  the  upper,  and  extension  in  the  lower  ex- 
tremity.' In  time  the  muscles  waste  and  all  utility  of  the 
limb  is  lost.  The  bilateral  muscles  of  the  trunk  suffer 
little  in  late  rigidity.  It  is  always  held  that  the  prospects 
of  recovery  of  power  are  better  when  the  leg  begins  to  come 
round  before  the  arm,  than  when  the  opposite  is  the  case. 
Persons  who  have  had  '  a  stroke '  often  can  walk  fairly 
well,  when  the  hand  remains  of  little  use.  When  the 
injured  person  commences  to  walk,  then  the  gait  becomes^ 
modified  in  a  characteristic  manner.  When  the  affected 
limb  is  being  moved  the  shoulder  of  the  healthy  side  is- 
thrown  outwards,  and  the  hip  of  the  paralysed  side  raised 
so  as  to  swing  the  leg  round,  the  toe  commonly  trailing  on 
the  ground.  If  the  walk  of  a  hemiplegic  person  be  once- 
studied,  the  movements  and  their  causation  are  made  plain 
for  ever  after. 

Then  the  spastic  hemiplegia  of  infants  is  a  distinct 
malady,  with  attacks  of  convulsions,  which  in  time  impair 
the  intellect. 

Incomplete  paralysis,  or  rather  impaired  power  of  one 
side,  is  not  uncommonly  seen  with  chorea. 

Alternate  hemiplegia,  'in  which  the  extremities,  half  the 
face  and  half  the  tongue,  are  paralj'sed  on  the  side  opposite,, 
and  the  oculo-motor  nerve  in  the  same  side  as  the  lesion,'  is 
the  characteristic  outcome  of  lesions  in  the  cerebral  peduncles. 
Spinal  hemiplegia   gives   paralysis   with   hypertesthesia  on 


I 


MOTOR  AND  SEXSORY  DISORDERS.  1S9 

one  side  ;  with  anaesthesia  of  the  opposite  side ;  and  fre- 
quently the  paralysed  muscles  quickly  waste.  '  Acute  bed- 
sore may  appear  on  the  anesthetic,  and  inflammation  of  the 
knee-joint  on  the  paralysed  side  ;  while  well-marked  ataxia 
may  be  observed  on  the  return  of  motor  power  in  the 
paralysed  leg.'  When  the  mischief  is  high  up  the  upper 
extremity  is  involved. 

Paraplegia. — Tliis  is  paralysis  of  both  sides,  extending 
from  the  lower  limbs  upwards.  It  may  be  due  to  disease  in 
the  cord,  syphilitic  or  other,  or  to  injury.  The  sphincters 
are  more  or  less  involved,  according  to  the  seat  of  the  disease, 
and  its  nature  and  extent.  Paraplegia  is  not  uncommon  in 
women  as  a  result  of  utero-ovarian  trouble,  and  is  then 
called  hysterical,  or  reflex ;  and  usually  tlie  diagnosis  is  not 
difficult. 

The  paraplegia  with  an  inflammatory  zone  in  the  cord 
has  spasms,  which  are  absent  in  spinal  anaemia.  Conse- 
quently spasms  with  paraplegia  point  to  conditions  of 
actual  disease.  Paraplegia,  more  or  less  complete^  is  often 
found  in  young  women  along  with  that  group  of  symptoms 
called  '  spinal  irritation.'  When  paraplegia  is  due  to 
myelitis  the  sphincters  are  affected,  and  bedsores  readily 
form.  (The  ready  formation  of  bedsores  shows  the  trophic 
nerves  are  injured.)  Cervical  paraplegia  gives  a  slow  pulse 
and  a  dilated  or  contracted  pupil,  while  the  arms  are  in- 
volved. 

A  gradual  impairment  of  the  motor  power  in  the  lower 
limbs  is  seen  in  elderly  men  with  slowly  progressing 
disease  of  the  brain  and  cord.  The  walk  degenerates 
gradually  Crom  '  the  sure  and  certain  step  of  man  '  into 
a  mere  shuffle ;  and  the  step  is  less  than  the  length  of  the 
foot. 

Pteflex  paraplegia  is  also  seen  at  times,  and  is  one  conse- 
quence of  fracture  of  the  coccyx. 

In  cancer  aff"ecting  the  cord  there  is  usually  severe  local 
pain.     In  that  modification   of  gait   known   as   locomotor 


I90         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

ataxy  there  are  commonly  'lightning  pains,'  which  are  very 
acute. 

Gait. — Some  general  observations  may  now  be  made  as 
to  the  modification  of  the  gait  produced  by  various  ner- 
vous diseases.  Dr.  Hughlings  Jackson  showed  me  him- 
self  the  modifications  so  produced,  by  imitating  them. 
They  run  briefly  as  follows.  First  comes  ordinary  hemi- 
plegia : 

HemiiDlegia. — In  hemiplegia  the  shoulder  is  tilted  to  the 
healthy  side  so  as  to  raise  the  pelvis  of  the  aflfected  side, 
and  thus  enable  the  leg  to  be  swung  round  ;  the  knee-action 
being  largely  abolished.  The  shoe  becomes  worn  at  the 
toe,  as  it  is  trailed  on  the  ground  at  each  step.  The  arm 
often  hancjs  down  rifjid  and  useless. 

Paraplegia. — Here  the  legs  do  not  step,  but  trail  or 
shuffle;  both  of  them!  While  the  '  step  '  is  not  the  length  of 
the  shoe  in  advanced  cases. 

Hysterical  Paralysis. — Here  the  feet  are  dragged  along, 
one  more  marked  than  the  other ;  while  the  patient  is  apt 
'  to  drop  in  a  lump.'  (In  true  paraplegia  the  patient  does 
not  drop  so  long  as  the  power  of  walking  remains.) 

Paralysis  Agitans. — Here  the  patient  trots  forward,  an 
exaggeration  of  the  actor's  walk  when  appearing  on  the 
stage  ;  while  the  shaking  hands  are  held  out  in  front  of  the 
body,  which  is  bent  forward. 

Progressive  Muscular  Atrophy. — Here  the  gait  is  that 
of  the  sailor  before  he  has  got  his  '  land-legs,'  only  exagge- 
rated ;  while  the  muscles  of  the  ball  of  the  thumb  are 
wasted,  and  if  the  patient  attempt  to  unbutton  his  waist- 
coat, he  thrusts  at  the  buttons  with  the  dorsal  aspect  of 
his  fingers. — Pearson  Irvine. 

Pseudo-hypertrophic Paralysis. — Here  there  is  a  waddle  or 
'  duck-like  walk,'  not  unlike  that  of  talipes  varus.  ' "  Is  that 
the  long  word  you  call  it  when  a  fellah  walks  so  ?"  said  the 
young  man,  making  his  fists  revolve  round  an  imaginary 
axis.' — Oliver  Wendell  Holmes. 


*-  MOTOR  AND  SENSORY  DISORDERS.  191 

Reflex  Paralysis. — Here  the  leg  of  one  side  is  trailed  to  a 
greater  or  less  extent. 

Locomotor  Ataxy. — Everyone  is  familiar  with  the  manner 
in  which  the  leg  is  snatched  up  and  brought  down  with  a 
'flop'  (the  'trampers  '  of  spas);  an  action  much  exaggerated 
when  the  eyes  are  closed. 

Cerebellar  Disease. — Here  the  gait  is  that  of  a  drunken 
person,  staggering,  unsteady,  reeling  the  '  cerebellar  reel.' 

Syphilitic  Disease. — This  produces  a  crooked  spine^  and 
sprawling  legs,  like  a  '  daddy-long-legs' '  walk ;  quite  in- 
describable, but  characteristic  enough  when  Professor  W. 
T.  Gairdner  imitates  it.  (The  lesion  may  be  in  the  cord,  or 
cerebral  with  secondary  degeneration,  and  the  result  would 
lay  therewith.) 

*  The  Spasmodic  Gait  or  Spastic  WalJc. — The  combined 
paresis,  stiffness,  and  tremors  of  the  lower  extremity  render 
the  gait  quite  characteristic.  The  foot  seems  to  cling  to  the 
ground,  from  which  it  is  detached  with  difficulty,  and  as  it 
is  made  to  slide  forwards,  it  produces  a  characteristic  scrap- 
ing noise ;  while  the  toes  find  an  obstacle  in  every  eleva- 
tion of  the  ground,  and  the  patient  readily  tumbles  and 
falls.' 

In  Hip- joint  Disease,  in  the  early  stage  the  limb  is 
straight,  carried  forward,  or  perhaps  somewhat  abducted ; 
w^iile  as  the  disease  advances,  the  limb  becomes  adducted, 
so  that  the  knee  is  carried  against  the  lower  part  of  the 
sound  thigh. — (Erichsen.) 

Of  course,  as  well  as  these,  there  are  changes  wrought  by 
rheumatism  ;  by  osseous  changes  ;  by  gout,  corns,  a  sprain,  or 
a  tight  shoe,  or  boot;  or,  maybe,  a  cork  leg;  also  alcoholic 
excess. 

Monoplegia. — A  cervical  lesion  may  be  so  localised 
that  a  very  limited  paralysis  may  follow.  As,  for  instance, 
one  arm  may  alone  be  paralysed,  or  only  one  side  of  the 
face  may  be  affected,  or  there  may  be  a  *  crural  mono- 
plegia.'    Such   monoplegic   attacks   do   not  involve  sensa- 


192         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

tion.    The  muscles  of  the  eye  seem  specially  liable  to  mono- 
plegia. 

Then  as  well  as  impaired  riiohiltty  there  are  abnormal 
muscular  movements  to  be  considered. 

Convulsions. — These  are  commonly  seen  in  the  malady 
called  epilepsy.  They  may  be  bilateral,  or  unilateral,  or 
restricted  to  a  group  of  muscles.  The  tongue  is  usually 
bitten  in  severe  attacks  ;  and  the  scars  on  the  tongue  tell  of 
an  old  epileptic  history.  Epilepsy  may  be  unconnected 
with  organic  disease,  and  have  no  significance  bej^ond  un- 
fitting a  man  for  certain  occupations,  as  that  of  a  slater,  or 
sailor,  for  instance.  But  it  is  a  common  phenomenon  of  many 
forms  of  disease,  notably  the  general  paralysis  of  the  insane. 
The  number  and  severity  of  the  'fits  '  are  a  common  test  of 
the  progress  of  the  malady,  or  the  success  of  the  treatment. 
When  fits  are  numerous  and  recurrent,  then  the  status 
epilepticus  is  induced,  with  marked  deterioration  of  the  in- 
tellect. Or  death  from  exhaustion  may  follow  an  outburst 
of  fits.  In  the  petit  mal  a  twitch  of  a  few  muscles,  a  fixed 
gaze,  or  a  burst  of  unmeaning  laughter  may  be  all  the 
muscular  disturbance  set  up.  Sometimes  there  is  merely 
a  '  monospasm.' 

Then  there  are  hysterical  convulsions,  which  may  be 
general  and  severe. 

Tetanus  is  a  most  dangerous  form  of  convulsions  ;  and  its 
marked  feature  is  opisthotonos. 

Closely  allied  to  this  last  is  hydrophobia. 

Convulsions  of  the  limbs,  of  the  lower  extremities  mainly, 
may  arise  from  spinal  congestion  or  inflammation,  or  from 
sclerosis  of  the  cord.  There  is  a  loss  of  motor  power  in  the 
last ;  while  '  on  lying  down,  and  especially  in  bed  at  night 
or  after  being  fatigued,  the  legs  become  subject  to  clonic  or 
tonic  spasms.'  In  time  contraction  follows.  These  irregular 
muscular  movements  are  readily  excited  by  slight  irritation 
of  the  skin,  especially  the  soles  of  the  feet. 

The  convulsions  may  be  *  toxic' 


MOTOR  AND  SENSORY  DISORDERS.  193 

Spasms. — Spasms  differ  from  convulsions  in  degree  rather 
than  in  nature.  Spinal  convulsions,  just  spoken  of,  indeed, 
are  generally  termed  spasms.  Spasms  are  classed  as  '  clonic  ' 
or  '  tonic' 

Tremor  is  mild  clonic  spasm ;  so  are  fibrillary  contractions. 
'  There  can  be  no  doubt  there  are  two  varieties  of  tremor, 
the  one  persisting  during  repose,  and  the  other  only  appear- 
ing when  the  patient  makes  a  voluntary  effort ;  but  whether 
the  former  is  due  to  pathological  irritation,  and  the  latter  is  a 
paralytic  phenomenon,  is  open  to  question.' 

'  General  convulsions '  are  the  opposite,  or  extreme  tremors. 
Then  tonic  spasms  involve  'cramp.' 

The  calf  of  the  leg  is  the  common  seat  of  cramp.  This  is 
■well  seen  in  labour,  when  the  head  of  the  foetus  is  pressing 
on  the  sacral  plexus  inside  the  pelvis.  Some  people  are 
liable  to  cramp  when  fatigued,  or  when  the  stomach  is  np- 
set;  while  cramp  is  certainly  often  causally  related  to 
gout.  A  load  in  the  bowels  is  often  found  with  cramp. 
Diarrhoea  ma}^  set  up  cramp  in  the  abdominal  muscles  as 
well  as  in  the  muscles  of  the  legs. 

Cramps  are  the  contractions  of  tetanus  and  catalepsy. 
Writers'  cramp  is  an  affection  of  the  forearm-muscles  of  the 
fingers,  set  up  by  long  use  of  the  pen.  All  other  movements 
than  wielding  a  pen  can  be  performed  without  anything 
abnormal  occurring.  A  like  form  of  cramp  is  seen  with 
other  habits  involving  constant  use  of  the  fingers,  as  in 
violin  players. 

In  athetosis  there  is  a  peculiar  condition  of  the  fingers 
and  toes,  which  are  in  continual  movement  with  some 
spastic  tendency.  It  may  occur  with  certain  diseases  of  the 
nervous  system,  as  also  with  hysteria  in  women,  or  be  set 
up  by  teething  in  infants. 

There  is  a  form  of  convulsive  tremor  with  hyperaesthesia 
found  in  the  face,  arms,  and  trunk  ;  but  not  in  the  legs. 

Mercurial  tremor  is  arrested  by  supporting  the  shaking 
limb. 

13 


194         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS.  \ 

Chorea  and  paralysis  agitaiis  both  give  muscular  tremors. 
In  chorea  there  may  be  extensive  and  severe  contractions, 
continuing  in  sleep ;  or  there  may  only  be  localised  move- 
ments. Chorea  gives  erratic  movements,  very  irregular  in 
character.  While  in  shaking  palsy  the  movements  repeat 
themselves  '  rhythmically  and  symmetrically  on  the  two 
sides  of  the  body,  presenting  nothing  of  the  irregular 
and  rapidly  changing  character  of  the  true  choreic  move- 
ments.'— Da  Costa.  Chorea  is  a  disease  of  the  developing 
nervous  system,  very  commonly  linked  with  a  low  type  of 
nervous  system ;  while  paralysis  agitans  is  a  disease  of 
degeneration,  usually  senile,  of  the  nervous  sj^stem. 

Nystagmus  is  an  afi'ection  of  the  recti  muscles  of  the  eye, 
by  which  the  eyes  are  kept  in  incessant  movement,  often 
lateral,  or  at  other  times  rotator}^  These  movements  are 
aggravated  by  looking  at  a  distant  object,  while  they  are 
lessened  by  looking  at  anything  near,  or  a  small  .object. 
Nystagmus  may  be  of  no  significance,  or  it  may  indicate 
disease,  especially  about  the  cerebellum  and  its  peduncles. 

Spasm  of  the  ciliary  muscle  may  be  due  to  several  causes, 
as  strain  on  the  eye  ;  or  be  reflex,  or  toxic. 

Tic  convulsif,  or  blepharospasm,  is  a  very  curious  spasm 
of  the  muscles  around  the  eye,  a  sort  of  exaggerated  wink. 
It  may  be  a  mere  trick  of  no  significance,  and  as  such  seems 
to  have  some  relations  to  heredit}^  In  others  it  may  be 
brought  on  from  conditions  affecting  the  nervous  sj'stem, 
or  be  reflex.  This  'histrionic  spasm'  may  last  from  a  few 
seconds  to  a  few  minutes.  In  blepharospasm  the  eyelids 
are  closed;  in  nictitating  spasm  there  is  rapid  winking; 
in  risus  caninus,  or  sardonic  grin,  the  whole  side  of  the  face 
is  generally  implicated.  The  significance  of  this  twitch 
entirely  depends  on  its  causation.  If  it  has  alwa3^s  been 
present,  it  will  probably  continue.  If  it  is  of  recent  origin 
then  its  cause  must  be  sought  for. 

Just  as  neuralgia  has  its  '  tender  spots  of  Yalliex '  so 
there    are    'pressure    points'    with    spasmodic    afl'ections. 


MOTOR  AND  SENSORY  DISORDERS.  195 

Sometimes  pressure  on  one  of  the  spots  will  arrest  the 
spasmodic  action;  while  in  other  cases  such  pressure  will 
excite  it. 

Midway  betwixt  modifications  of  motility  and  sensation 
lies  the  feeling  of  '  pins  and  needles,'  or  of  the  limb  '  being 
asleep,'  experienced  from  pressure  on  a  nerve-trunk.  Tem- 
porary pressure  on  the  sciatic  nerve  will  give  the  feeling  of 
the  leg  being  '  asleep,'  while  motility  is  greatly  impaired  at 
the  same  time.  It  usually  passes  away  in  a  few  seconds. 
The  same  impairment  of  motion  with  modification  of 
sensation  is  found  in  the  arm  from  pressure  on  the  brachial 
nerve.  If  the  pressure  have  lasted  some  hours  (as  when  a 
drunken  person  falls  asleep  with  the  arm  over  the  back 
of  a  chair),  the  recovery  of  sensation  and  motion  is  more 
tedious. 

Trophic  Disturbances. — When  pressure  or  injury  to  a 
nerve-trunk  has  permanently  impaired  its  functional  power, 
then  trophic  disturbances  show  themselves,  and  the  skin  of 
the  extremity  is  '  glossy,'  and  shining,  while  the  pain  is 
'  burning ;'  or  ulceration  may  follow  injury  to  a  nerve-trunk. 
Weir  Mitchell,  in  his  work  on  'Injury  to  Nerves '  has  done 
much  to  point  out  modifications  of  nutrition  in  parts  where 
the  nerves  have  been  injured.  Indeed,  modifications  of 
nutrition  carry  with  them  a  distinct  value  at  times.  Thus 
*  the  nail  growth  is  abolished  in  recent  cerebral  palsies,  and 
its  renewal  maybe  made  an  element  of  prognosis  as  showing 
impending  recovery.  In  the  diagnosis  between  functional 
and  organic  palsies,  the  study  of  the  nail-growth  comes,  as 
Dr.  Mitchell  points  out,  completely  into  play,  and  is  likely 
to  be  of  some  value.' — Da  Costa.  When  motion  is  impli- 
cated, modification  of  nutrition  comes  in  in  two  ways.  There 
is  the  effect  of  disease,  pure  and  simple ;  and  there  is  the 
eifect  of  injury  to  the  trophic  nerve  fibrils,  held  to  run 
along  with  the  efierrent  motor  fibrils,  a  matter  which  we  can 
scarcely  yet  estimate.  As  seen  before,  p.  189,  modifications 
of  nutrition  follow  spinal  iniuries.     The  nerve-supply  of  a 

13—2 


196         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

part  is  as  essential  to  perfect  nutrition  as  is  the  blood  supply  ; 
if  not,  however,  to  an  equal  extent. 

Disorder  of  Sensation. — Like  the  disorders  of  motility, 
this  may  be  central,  or  due  to  something  affecting  the 
nerve-trunk,  or  be  reflex.  There  are  also  other  matters  than 
mere  impairment  of  sensation.  The  general  sense  of  touch 
and  the  sensation  of  pain  have  their  own  channels,  known 
as  the  '  tactile '  and  '  pathic '  channels,  as,  for  instance,  a 
patient  can  tell  when  he  is  touched,  but  cannot  distinguish 
betwixt  hot  and  cold  bodies ;  or  ordinary  sensation  is  un- 
affected, but  the  sensitiveness  to  temperature  is  exalted. 
When  botli  forms  of  cutaneous  sensibility  are  lost  the  condi- 
tion is  called  '  total  sensory  paralysis  ; '  if  one  only,  then  the 
term  '  partial  sensory  paralj^sis '  is  used,  or  '  partial  tactile 
paralysis,'  as  the  case  may  be.  Abnormal  sensations  may 
accompany  the  ansesthesia,  as  '  crawling,'  or  '  furriness.* 
Actual  pain  may  be  felt  in  the  anaesthetic  part. 

Ancestliesia. — This  may  be  felt  over  the  area  supplied  by 
a  nerve- trunk,  or  even  over  a  part  only  of  such  area.  In 
disease  of  the  spinal  cord  a  zone  of  pain  may  be  felt,  '  girdle 
pains,'  or  a  zone  of  anaesthesia.  Or  only  one  leg  may  be 
affected,  from  a  local  lesion  in  the  spine.  Hemi-ansesthesia 
is  accompanied  by  the  loss  of  taste  and  smell,  while  hearing 
and  vision  are  but  partially  affected.  Here  the  lesion  is 
situated  on  the  posterior  part  of  the  optic  thalamus ;  or  the 
affection  may  be  hysterical.  Analgesia  may  follow  the 
same  lines ;  and  so  may  '  thermo-an?esthesia.'  *  Tactile 
anaesthesia '  is  usually  found  in  patches  on  the  lower  ex- 
tremities, and  in  connection  with  disease  of  the  posterior,  or 
sensory  nerve-roots,  as  in  locomotor  ataxy.  Sensation  may 
also  be  retarded  ;  and  there  are  '  persistent  after-sensations  ' 
at  times  experienced.  Or  the  power  to  count  successive 
impressions  may  be  lost. 

Anaesthesia  may  be  peripheral,  as  the  result  of  cold,  or 
due  to  injury  to  the  nerve-fibrils  in  the  cord.  "When  the 
latter,  there   are   also   modifications   of  sensations,  as   the 


MOTOR  AND  SENSORY  DISORDERS.  197 

'  lightning  pains '  of  locomotor  ataxy,  and  tlie  impression 
of  walking  on  a  feather-bed,  etc.  That  is,  there  is  a  loss  of 
ordinary  sensation  with  certain  abnormal  sensations.  Nor 
is  anresthesia  experienced  in  the  skin  only ;  but  also  in  the 
mucous  membranes,  and  in  the  muscles,  as  '  muscular 
anaesthesia/  or  loss  of  the  sense  of  weight.  It  is  also 
experienced  in  locomotor  ataxy.  Anaesthesia  is  common 
with  the  insane,  especially  monomaniacs  and  general  para- 
lytics. Or  it  may  precede  a  cerebral  lesion.  Ansesthesia 
on  one  side  with  paralysis  on  the  opposite  side  is  the 
characteristic  of  a  spinal  lesion.  Then  ansesthesia  may  be 
'  reflex/  from  disorder  of  the  viscera,  or  from  irritation 
of  a  sensitive  nerve.  Loss  of  sensation  may  be  preceded 
by  increased  sensibility  in  the  nervous  centres  in  organic 
changes  which  first  increase  the  functional  activity  of 
a  sensory  area,  and  then  abolish  it.  A  curious  loss  of 
sensibility  may  occur  in  the  face  when  all,  or  part  of, 
the  fifth  nerve  is  affected.  Such  trigeminal  ansesthesia  may 
be  of  rheumatic  origin — Romberg.  According  to  Vulpian, 
sensation  is  rather  retarded  than  lost  in  sclerosis  of  the  cord. 
When  the  vagi  are  affected  the  sense  of  hunger  may  ex- 
perience no  abatement  by  taking  food. 

One  great  difficulty  about  disorders  of  sensation  is  how 
to  measure  the  amount  of  sensibility.  In  palsies,  the  facts 
are  fairly  palpable ;  in  losses  of  sensation,  there  is  the 
patient's  interpretation  of  the  sensation,  or  the  loss  of  it,  to 
be  taken  into  the  calculation.  Much  caution  is  often  requisite 
in  accepting  the  statements  made,  and  repeated  examina- 
tion, electric  and  other,  may  be  necessary  to  verify  the 
statements  made  as  to  what  is  actually  experienced. 

Something  may  now  be  said  briefly  as  to  some  special 
modifications  of  sensation.  When  a  mixed  nerve  is  afiected 
there  may  be  modifications  of  irritability,  of  sensation,  or  of 
nutrition  ;  and  according  to  these  may  the  seat  of  the  lesion 
be  ofttimes  diagnosed.  Thus  Romberg  said  of  the  fifth 
nerve,  when  single  filaments  are  alone  aflTected,  the  lesion  is 


198  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

peripheral ;  when  the  face  and  oral  cavity  are  affected, 
the  disease  involves  the  sensory  fibres  of  the  fifth  before  it 
divides ;  when  the  entire  area  is  affected,  the  disease  is 
situate  in  or  near  the  Gasserian  ganglion;  when  also  the 
third  or  sixth  nerves  are  implicated,  and  there  is  atrophy 
of  the  optic  nerves,  the  disease  is  in  the  base  of  the  brain. 
By  remembering  the  anatomical  relations  of  a  mixed  nerve 
along  with  the  precise  disturbance  of  sensation,  the  exact 
seat  of  the  lesion  may  be  determined. 

The  sense  of  smell  may  be  diminished  by  disease  in  the 
periphery,  in  the  trunk,  or  the  centres.  Anosmia  is  common 
with  hysteria,  general  paralysis  of  theinsane,  or  senile  atrophy. 
It  may  be  the  result  of  a  blow  or  a  fever,  or  it  may  arise 
from  a  catarrhal  condition  of  the  Schneiderian  membrane 
from  cold.  In  these  last  cases  anosmia  is  of  less  significance 
than  when  due  to  cerebral  lesions.  False  smells  and 
imaginary  smells  are  experienced  under  certain  circum- 
stances, especially  with  the  insane. 

The  sense  of  sight  is  liable  to  precisely  the  same  dis- 
turbance as  the  sense  of  smell,  and  is  more  commonly 
affected.  So  man}^  and  numerous  are  the  modifications  of 
sight,  that  a  brief  outline  is  all  that  may  be  attempted 
here.  The  acuteness  of  vision  may  be  lessened,  or  the  area 
limited,  or  there  may  be  intervals  of  complete  blindness  in 
ovarian  troubles,  or  the  sense  of  perception  of  colour  maj'' 
be  disturbed,  or  sight  may  be  defective  in  daylight,  or, 
more  commonly,  at  night  (hemeralopia).  "Without  ophthal- 
moscopic examination  it  is  often  impossible  to  determine 
whether  a  lesion  as  hemiopia  be  retinal,  or  be  due  to 
intracranial  disease ;  perhaps  in  the  latter  the  line  of 
demarcation  is  not  so  sharply  defined.  In  some  cases  it  is 
obvious  that  the  eye  itself  is  at  fault ;  while  in  amaurosis 
the  eye  is  clear  and  bright,  perhaps  sometimes  wanting  in 
expression.  When  only  one  eye  is  affected  the  causal 
lesion  is  local  probably.  Flashes  of  light  in  the  eye  are  the 
result  of  a  blow,  or  may  be  linked  with  megrims,  or  with 


MOTOR  AND  SENSORY  DISORDERS.  199 

insanity.  Abnormally  acute  sight  may  be  natural,  or 
belong  to  a  pathological  condition.  The  sense  of  hearing 
is  commonly  affected  in  cerebral  congestion,  as  in  the 
ringing  of  bells,  of  cinchonism  and  delirium,  or  exaltations 
of  hearing.  While  in  conditions  of  general  debility,  the 
sense  of  hearing  is  greatly  impaired.  The  blind  usually 
possess  a  most  acute  sense  of  hearing,  probably  from 
training  the  ear  to  make  up  for  the  eye.  Deafness  may  be 
due  to  disease  in  any  part  of  the  ear  or  the  auditory 
mechanism,  and  may  be  partial  or  complete,  as  the  case 
may  be.  The  tick  of  a  watch  may  not  be  audible  when 
held  to  the  ear,  but  be  distinct  when  the  watch  is  placed 
betwixt  the  teeth ;  in  the  last  case  the  lesion  is  peripheral, 
and  not  central.  The  'knocking,'  or  'whirring,'  or  'buzzing' 
often  complained  of  is  usually  nothing  more  than  the 
pulsations  of  a  poorly  filled  carotid  artery  upon  the  petrous 
portion  of  the  temporal  bone ;  or  it  may  be  found  with  an 
atheromatous  condition  of  the  arterial  walls.  Sometimes 
auditory  illusions  are  experienced  in  complete  deafness, 
from  disease  of  the  auditory  nerve,  just  as  is  the  case  with 
disease  of  the  optic  nerve.  A  blind  Jewess  in  the  Sal- 
petriere  had  the  most  fearful  visions,  and,  on  post-mortem, 
the  optic  nerves  were  found  to  be  involved  for  a  con- 
siderable length  in  cancerous  disease. 

The  sense  of  taste  is  also  liable  to  disturbance.  This 
varies  in  significance  according  to  the  part  affected,  the 
nervous  connections  of  taste  being  complex.  Extremely 
acute  taste,  or  the  loss  of  it,  may  depend  on  passing  condi- 
tions, as  a  fever;  or  may  indicate  cerebral  lesions,  or  disease 
in  the  track  of  the  nerves. 

Lesions  of  the  chorda-tympani  due  to  disease  of  the  tem- 
poral bone  may  produce  loss  of  the  sense  of  taste  in  the 
anterior  portion  of  the  tongue. 

It  would  serve  no  good  end  to  attempt  to  lay  before  the 
reader  any  sketch  of  the  relations  of  modifications  of  spinal 
sense  or  of  general  sensations.     What  has  been  attempted 


200        PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

is  some  account  of  the  circumstances  under  which  such 
sensory  modifications  arise.  What  the  reader  must  do,  and 
he  must  do  it  for  himself  in  each  case,  is — not  to  lose  his 
head,  and  get  into  a  muddle ;  but  to  keep  the  relations  of 
the  modifications  in  his  eye,  and  follow  out  the  anatomy  of 
the  afiected  nerve  carefully  and  with  pains.  If  this  be  pro- 
perly done,  the  seat  of  the  lesion  can  usually  be  '  tracked 
down,'  to  use  a  hunter's  phrase.  In  doing  this,  of  course  the 
associations  of  loss  of  sensation  are  valuable  :  thus  disease  in 
the  spinal  cord  will  give  abnormal  sensations  referred  to  the 
periphery  (eccentric  projection)  as  well  as  loss  or  diminution 
of  sensation.  Osteal  and  periosteal  changes  have  their  re- 
lations to  nervous  disturbances  (p.  181).  While  conditions 
of  the  circulation  within  the  encephalon  affect  the  special 
senses,  as  flashes  of  light,  and  noises  in  congestive  conditions  ; 
with  loss  or  diminution  of  any  of  the  senses  with  anaemic 
states,  as  in  the  convalescence  from  a  fever.  Indeed,  the 
employment  of  thought  is  essential  to  the  correct  interpreta- 
tion of  the  phenomena  ;  and  failure  or  erroneous  interpreta- 
tion is  more  often  due  to  want  of  pains,  or  application,  than 
to  the  inherent  difficulties  in  the  case  in  many  instances. 
Some  time  ago,  Dr.  Ferrier  diagnosed  a  tubercular  growth, 
very  localised,  in  the  cortex  of  the  motor  area.  After  death 
the  diagnosis  was  most  minutely  confirmed.  The  locality 
was  determined  by  his  special  information  as  to  localisation 
of  function  in  the  brain ;  but  as  to  the  nature  of  the  growth, 
his  accuracy  arose  from  his  educated  common-sense ;  the 
patient  had  exhibited  symptoms  of  tubercle  in  the  lungs. 
Between  the  two  a  very  clever  diagnosis  was  made. 

Hyperccsthesia. — A  good  deal  has  been  said  about  hyper- 
sesthesia  in  the  preceding  section,  which  could  not  be 
avoided,  and  need  not  be  repeated  now.  Hyperfesthesia  as 
to  locality  and  temperature  may  occur  with  heightened  com- 
mon sensibility  as  to  pain,  as  in  vesicular  skin  affections.  It 
may  be  felt  over  small  or  large  areas,  like  angesthesia  ;  and 
may  precede  the  latter.     A  girdle  sensation  as  of  a  cord 


MOTOR  AND  SENSORY  DISORDERS.  -or 

being  tied  round  the  body  '  is  a  very  common  accompani- 
ment of  all  spinal  diseases.' 

Hyperalgesia  is  an  exquisite  sensitiveness,  when  pain  is 
produced  by  slight  causes,  scarcely  felt  by  persons  in  health, 
A  highly  developed  nervous  system  in  a  woman  will  give 
heightened  sensitiveness  to  all  sensory  organs  at  certain 
times  and  under  circumstances,  to  an  extent  scarcely  credible. 
A  touch  will  produce  pain  ;  while  sight  and  hearing  are 
greatly  exalted,  and  taste  and  smell  are  involved. 

Ahnormal  Sensations. — These  are  common  with  the  in- 
sane, and  not  rare  with  the  sane.  Thus  pruritus  or  itching 
is  found  with  local  causes,  as  scabies ;  with  glycosuria  there 
is  pruritus  vulvae  in  women;  ascarides  cause  rectal  itching; 
while  a  general  itching  of  the  skin  is  known  in  choljemia, 
uraemia  (jaundice  and  lithiasis),  and  in  diabetes.  Formica- 
tion may  be  due  to  irritation  at  any  part  of  sensory  nerve- 
fibrils.  It  is  felt  when  the  olecranon  is  hit,  or  the  leg  is 
'  asleep ; '  and  is  cerebral  at  times,  or  due  to  some  toxic 
agent.  Burning  is  related  to  trophic  neuroses  essentially. 
Thermo-hypersesthesia  is  linked  with  herpes  zoster,  and 
vesicated  areas  of  skin.  It  is,  too,  associated  with  spinal 
affections,  and  is  at  times  diagnostically  useful  in  sus- 
pected spinal  disease,  nervous  or  osseous.  Localised  sensa- 
tions of  heat  and  cold  are  felt,  just  as  there  are  patches  of 
local  anaesthesia  or  hypersesthesia  ('localised  spots  of  pain ') 
in  lithiasis,  in  hysteria,  or  in  organic  disease. 

Then  there  are  internal  sensations, — as  the  globus  of 
hysteria ;  cough,  from  irritability  of  the  air-passages ; 
anorexia  or  bulimia,  polydipsia,  pyrosis,  from  alterations 
in  the  mucous  lining  of  the  alimentary  canal;  while  poly- 
dipsia may  be  due  to  something  affecting  the  nerve- 
endings  which  participate  in  the  sensation  of  thirst.  The 
sensations  connected  with  the  reproductive  instinct  may  be 
exalted  by  peripheral  causes,  by  centric,  or  even  mental 
causes,  or  by  irritation  in  the  conducting  apparatus.  While 
anaesthesia  of  the  generative  orcjans  is  not  uncommon  with 


202         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

hysterical  women.  Spinal  disease,  or  injury,  may  produce 
either  of  these  results.  ■ 

A  general  sense  of  oppression,  or  of  impairment  of  power, 
is  found  with  general  exhaustion,  or  with  exhaustion  of  the 
posterior  lobes.  Hysteria  will  give  all  and  every  modifica- 
tion of  sensation  and  abnormal  feeling  that  disease  can 
induce.  Indeed,  its  'mimetic'  power  is  boundless.  The 
prognosis  is  widely  different,  however,  in  hj'^steric  and 
organic  cases. 

In  diagnosis,  in  relation  to  prognosis,  the  element  of 
syphilis  always  improves  the  prospects  from  its  known 
amenability  to  treatment.  Of  course,  too,  in  this  matter  the 
effects  of  treatment  are  often  of  primary  value  in  clearing 
up  the  diagnosis. 

Indeed,  the  effects  of  treatment  in  many  cases  are  essential 
to  determine  the  diagnosis,  as,  for  instance,  in  the  impair- 
ment of  the  brain,  as  the  organ  of  mind ;  in  cerebral  ex- 
haustion as  distinguished  from  like  impairment  in  the 
organic  changes  commonly  spoken  of  as  '  softening,'  but 
probably  rather  the  opposite  pathological  condition,  'scle- 
rosis.' 


CHAPTER  XT. 

THE   patient's   SENSATIONS. 

This  is  a  decidedly  important  matter,  both  for  the  informa- 
tion it  gives,  and  the  opportunity  it  affords  of  showing  the 
patient  tliat  you  know  what  you  are  talking  about  — 
albeit  a  subject  of  which  little  can  be,  or  is  usually,  learned 
in  the  medical  curriculum.  When  familiar  with  a  disease, 
it  is  often  possible  to  realize  the  patient's  sensations,  and 
put  the  questions  seriatim,  so  as  to  evidence  familiarity  in 
a  conspicuous  manner.  The  first  matter  is  shortness  of 
breath,  of  which  something  has  been  said  before,  at  p.  55. 

Shortness  of  Breath. — This  has  been  shown  before  to  be 
connected  with  diminution  of  the  lumen  of  the  air-tubes,  or 
infringement  upon  the  thoracic  space  by  air,  fluid,  or  growth. 
Anything  which  diminishes  the  space  for  residual  air  in  the 
chest  cuts  down  the  capacity  for  exertion.  We  all  have  a 
great  deal  of  what  is  called  '  spare '  lung — that  is,  an  excess 
beyond  what  is  required  when  the  body  is  at  rest.  With- 
out such  spare  lung,  it  would  be  impossible  to  make  an 
effort.  When  the  lung  space  is  infringed  upon,  no  matter 
by  what,  then  the  margin  beyond  the  indispensable  minimum 
is  cut  down  in  strict  proportion  to  the  extent  of  the  in- 
truder. Consequently  there  are  times  when  the  character  of 
the  respiration,  and  the  effect  of  effort,  will  tell  you  a  greatdeal 
that  you  very  much  like  to  know.  For  instance,  in  chronic 
bronchitis,  in  emphysema,  in  disseminated  fibrosis  of  the 
lung,  the  effect  of  effort  in  heightening  the  respirations  will 


204         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

tell  how  extensive  the  mischief  is,  when  physical  examina- 
tion may  be  dumb  by  comparison.  In  most  cases  the 
physical  examination  will,  of  course,  tell  clearly  of  the 
extent  of  the  disease  ;  but  there  are  some  cases  where  it 
does  not,  and  then  'the  physiological  factor'  is  of  paramoimt 
importance. 

But  there  are  some  conditions  where  the  physical  signs 
can  tell  nothing.  What  are  the  physical  signs  of  fatty 
degeneration  of  the  heart  ?  They  are  nil,  or  nearly  so  ! 
But  the  inability  to  make  an  effort  will  often  give  a  most 
suggestive  hint.  There  may  be  other  suggestive  matters, 
as  tendency  to  swimming  in  the  head,  or  loss  of  power, 
telling  that  the  heart  structures  are  impaired,  and  cannot 
keep  up  the  blood-pressure  in  the  arteries  of  the  brain. 
There  may  indeed  be  a  number  of  indications  which, 
taken  together,  make  up  a  pretty  clear  case.  If  there  be 
evidences  of  senile  changes  in  the  individual  as  well,  then 
little  reasonable  doubt  would  remain. 

But  there  is  another  condition  where  the  heart  and  dia- 
phragm are  both  greatly  impaired  in  power,  and  that  is 
when  the  assimilation  of  albuminoids  is  very  defective. 
These  two  muscles,  in  unceasing  action,  feel  the  malnutrition 
more  keenly  than  any  other  part  of  the  body.  This  condi- 
tion has  been  described  by  myself  as  '  heart  starvation  ' — a 
term  giving  a  vivid  conception  of  the  actual  condition  of 
affairs.  Here,  also,  the  capacity  for  effort  is  greatly  cut 
down  in  proportion  to  the  deficient  assimilation.  In  the 
one  case  the  muscular  fibre  is  decaying ;  in  the  other  it  is 
underfed.  In  each  case  there  is  a  loss  of  functional  power. 
So  far  as  function  is  concerned,  then,  the  two  conditions  are 
closely  alike.  But  the  one  is  distinctly  '  senile,'  while  the 
other  is  by  no  means  necessarily  so.  A-  tottering  old  man, 
the  subject  of  extensive  senile  changes,  and  a  ^''oung  or 
middle-aged  man  brought  down  by  dysenterj',  may  hardly 
be  distinguishable  at  some  distance,  or  to  a  casual  glance ; 
but  when  seen  closer,  the  resemblance  fades  away  as  the 


THE  PA  TIENTS  SENS  A  TIONS.  205 

points  of  difference  become  more  distinct.  So  it  is  with 
'  fatty  degeneration  '  and  its  double,  '  heart-starvation.'"^  It 
is  important  to  make  this  distinction,  which  is  not  always 
made.  It  does  not  redound  to  the  credit  of  a  medical  man 
to  diagnose  fatty  degeneration  of  the  heart,  when  many 
years  afterwards,  with  sound  tissues,  the  patient  comes  to 
tell  the  tale  as  another  '  doctor's  mistake  ' ! 

It  is  a  condition  which  marks  the  convalescence  from 
acute  fevers,  where  all  the  muscles  have  undergone  an 
acute  degeneration  (under  the  high  temperature)  ;  as  such 
it  is  often  very  distinct  after  relapsing  fever.  Both  this 
last  and  'heart-starvation'  present  the  same  features  of 
impaired  power  in  the  heart  and  diaphragm  as  are  charac- 
teristic of  fatty  degeneration;  but  then  that  does  not  justify 
a  diagnosis  of  the  latter,  which  is  essentially  a  senile  change 
with  the  worst  possible  prognosis. 

Syncope. — Syncope  or  'swooning'  may  be  the  result  of 
emotion,  and  when  found  with  females  is  usually  a  mere 
temporary  affixir.  (Now  that  it  has  ceased  to  be  fash  ion- 
able,  'fainting'  is  much  less  common.)  A  shock  may 
anfesthetise  the  brain  by  inhibiting  the  action  of  the  heart ; 
it  may  do  it  so  effectually  as  to  produce  actual  death.  Then 
swooning  may  occur  when  the  heart's  action  is  inhibited 
from  other  causes  which  throw  the  inhibitory  fibres  of  the 
vagus  into  action,  as  irritation  elsewhere.  In  a  less  degree 
'feeling  faint'  is  comparatively  common,  and  may  arise 
from  some  gastric  cause  acting  through  the  vagus  ;  especially 
when  there  is  also  flatulence  or  gas  in  the  stomach  pressing 
on  the  heart  through  tlie  thin  wall  of  the  diaphragm. 
Romberg  relates  a  case  of  temporary  arrest  of  the  heart's 
action  frora  a  tumour  involving  the  vagus,  where  'there  was 
an  intermission  of  live  or  six  beats  of  the  heart.    The  aspect 

*  A  critic  has  taken  me  to  task  for  this  expression  as  '  sensational ;' 
but  he  suggested  no  better  term.  '  The  sabre  strokes  of  Saxon  speech' 
are  most  expressive  in  their  fitness  at  times.  I  know  no  more  suitable 
term. 


2o6         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

of  the  patient  shovv^ed  that  at  the  time  something  terrible 
■was  going  on  within  him ;  he  sat  there  as  if  thunderstruck 
(attonitus),  speechless,  motionless,  his  eyes  wide  open,  his 
consciousness  unimpaired.'  Here,  curiously,  there  was  no  loss 
of  consciousness,  only  loss  of  all  motor  power  in  the  attack. 
Recently  a  case  of  inhibited  action  from  some  meningeal 
thickening  in  the  upper  portion  of  the  dorsal  spinal  cord 
-came  under  my  notice.  Long  periods  of  unconsciousness 
occurred  in  another  case,  where  the  heart  muscle  was  largely 
weakened  by  typhoid  fever.  Attacks  of  unconsciousness 
lasting  some  time — long  swoons,  in  fact — have  come  before 
me  not  rarely  in  connection  with  aortic  stenosis  ;  and  when 
a  strongly  built  person  advanced  in  life  complains  of  the 
oncome  of  fainting  attacks,  it  is  well  to  examine  for  this 
lesion  ;  if  not  present,  the  case  will  probably  turn  out  to  be 
one  of  fatty  degeneration. 

Palpitation. — The  sensation  of  palpitation  is  one  commonly 
complained  of  by  patients.  It  may  occur  with  three  dis- 
tinct conditions,  and  has  a  significance  accordingly.  These 
are  (1)  muscular  failure,  (2)  lithiasis,  and  (3)  as  a 
neurosis. 

1.  Palpitation  from  muscular  failure.  This  form  of  palpi- 
tation is  distinctly  related  to  effort.  When  a  demand  upon 
the  heart  is  made,  it  either  fails,  giving  syncope ;  or  it  acts 
tumultuously,  or  palpitates.  When  a  heart  palpitates  on 
effort,  its  muscular  power  is  impaired.  A  dilated  heart 
always  palpitates  on  effort,  even  when  the  dilatation  is 
blended  with  hypertrophy  ;  the  more  the  hypertrophy,  the 
greater  the  power  to  sustain  effort.  When  a  heart,  once 
hypertrophied,  begins  to  undergo  structural  decay,  then 
palpitation  on  effort  is  manifested;  and  when  an  elderly 
person  complains  of  palpitation  coming  on,  such  morbid 
change  may  be  legitimately  suspected,  whether  there  be 
any  valvular  mischief  present  or  not. 

Palpitation  on  effort  may,  however,  be  manifested  under 
a  totally  different  set  of  circumstances.     Some  people  have 


p  THE  PATIENTS  SENSATIONS.  207 

large  hearts,  just  as  some  people  have  large  noses ;  others 
have  small  hearts,  while  others  have  small  noses.  Latham 
describes  a  class  of  beings  with  congenitally  small  hearts, 
who  were  unequal  to  great  efforts ;  while  the  endurance  of 
the  racehorse  Eclipse,  and  of  the  greyhound  Master 
Magrath,  has  been  attributed  to  the  '  huge  blood-pump ' 
found  in  each.  Persons  with  very  large  hearts  are  verv 
'  long- winded/  to  use  an  athlete's  phrase — remarkable  for 
their  power  of  holding  out.  Persons  with  small  hearts  are 
*  short-winded,'  and  if  one  of  this  class  is  ambitious  to  be 
an  athlete,  his  aspirations  not  uncommonly  end  in  palpita- 
tion on  effort,  until  he  abandons  his  elected  pursuit.  Or 
even  a  very  good  heart  may  be  so  disabled  by  over-effort 
from  distension  of  the  right  ventricle,  as  after  violent  long 
runs,  and  afterwards  readily  palpitate.  This  is  the  condi- 
tion of  '  broken-windedness '  in  horses  which  have  been 
over-galloped,  and  which  is  recovered  from  on  being  turned 
out  to  grass.  With  quiet,  the  ventricle  recovers  itself;  and 
the  condition  is  totally  different  from  the  gradually 
increasing  '  broken-windedness  '  of  advancing  emphysema. 
Palpitation  on  effort,  then,  has  several  associations,  in  all 
of  which  impairment  of  the  heart's  power  as  a  muscle  is 
involved. 

The  palpitation  of  approaching  dissolution  is  thus  de- 
scribed by  Hope  :  '  It  must  be  recollected  that,  in  every 
organic  disease  of  the  heart,  when  palpitation  becomes 
extremely  violent  and  prolonged,  both  the  impulse  and  the 
sounds  may  be  diminished;  in  other  words,  the  heart 
becomes  gorged,  and  incapable  of  adequately  contracting  on 
its  contents,  sometimes  yielding  a  struggling,  convulsive 
impulse,  with  little  sound  and  a  feeble  pulse,  and  in  an 
ulterior  degree,  especially  during  dissolution,  scarcely  joro- 
ducing  either  impulse,  sound,  or  pulse.  Suffocation, 
dyspnoea,  lividity,  and  extreme  distress  are  always  con- 
comitant symptoms.' 

2.  Palintation  in  Lithiasis.  When  the  blood  is  loaded 


2o8         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

with  nitrogeuised  waste,  not  only  is  the  blood-pressure  in 
the  arteries  high  ;  but  there  are  also  times  when  this  high 
blood-pressure  is  further  raised  by  spasm  of  the  arterioles. 
Such  a  condition,  when  very  marked,  gives  angina  pectoris, 
or  '  breast  pang,'  when  the  heart  is  acutely  distended,  and 
though  struoforling  its  hardest,  giving  little  sign  thereof ; 
much  as  in  the  condition  above  taken  from  Hope.  When 
the  heart  can  resist  the  distension  somewhat,  it  palpitates  in 
its  struggle,  and  'gouty  palpitation'  is  the  result.  This 
gouty  palpitation  is  less  serious  than  angina ;  in  fact,  angina 
is  most  grave  when  the  heart  is  too  rotten  to  attempt  such 
a  struggle. 

This  form  of  palpitation  is  not  linked  with  effort,  but 
comes  on  at  other  times  ;  often  the  palpitation  is  distinctly 
clear  of  any  relation  to  effort,  and  then  there  is  compara- 
tively little  difficulty  in  the  diagnosis.  But  as  often  a 
mixed  condition  is  found,  especially  in  women.  There  is  a 
dilated  heart  in  a  gouty  person,  and  then  there  are  both 
'  gouty  palpitation  '  and  '  palpitation  on  effort '  found  to- 
geth  er. 

3.  Neiirosal  Palpitation.  Palpitation  as  a  neurosis  may  be 
found  along  with  both  of  the  other  forms  of  palpitation,  or 
be  quite  independent  of  either.  Thus  it  may  arise  from  any 
mental  cause  of  excitement  or  alarm  ;  or  be  a  part  of  an 
extensive  neurosis,  as  in  chorea  and  exophthalmic  goitre,  in 
both  of  which  maladies  the  heart  may  beat  so  violently  that 
it  seems  as  if  it  would  burst  its  prison  wall,  or  shatter  off 
the  front  of  the  chest.  It  is  common  with  ovarian  irrita- 
bility (see  p.  15-5),  and  the  irritation  set  up  in  the  ovary 
may  terminate  in  paroxysms  of  palpitation.  Such  palj)ita- 
tion  may  occur  in  the  day,  or  only  occur  during  sleep,  '  the 
period  'par  excellence  of  reflex  excitability.'  In  the  latter 
case  the  sufferer  is  awakened  out  of  sleep  by  violent  palpita- 
tion, all  the  more  alarming  if  at  intervals  the  heart  feels  as 
if  it  would  stop.     Such  is  *  reflex  '  palpitation. 

Hope  divided  the  exciting  causes  of  hypertrophy  of  the 


THE  PATIENTS  SENSATIONS.]  209 

heart  into  (1)  nervous  and  (2)  mechanical.  He  says  :  '  The 
former  class  comprises  all  moral  affections  and  all  derange- 
ments of  the  nervous  functions  that  excite  long-continued 
palpitation.'  When  such  *  nervous  hypertrophy '  is  en- 
countered, as  in  certain  cases  of  exophthalmic  goitre,  for 
instance,  the  palpitation  is  violent,  persistent,  and  intract- 

1   able. 

Sometimes  the  heart  has  a  very  tumultuous  action,  not 

I   amounting  to  palpitation  at  all  times  ;  but  ready  to  palpitate 

i  on  slight  exciting  causes.  Such  heart  is  usually  found  in 
young  women,  and  may  be  termed  a  '  badly  behaved  heart ;' 
and  a  very  inconvenient  possession  it  is  for  its  owner. 

It  is  almost  needless  to  say  that  the  exciting  causes  of 
nervous  palpitation  will  readil}'  affect  a  heart  liable  to  the 
first  described  forms  of  palpitation. 

Palpitation  in  hysteria  is  complex  in  origin.  It  is  a 
neurosis  in  itself ;  and  yet  it  is  partly  due  to  arterial  spasm, 
for  it  is  found  with  a  tight  artery,  and  followed  by  a  large 

^,  flow  of  limpid  urine. 

P  Palpitation  may  often  be  a  complex  affair  with  several 
causal  relations ;  but  pains  will  usually  unravel  the  com- 
plexity, and  separate  the  different  component  factors.  Com- 
monly its  significance  is  easily  read. 

Pain. — In  many  maladies  pain,  of  some  form  or  other,  is  a 
prominent  complaint ;  sometimes  it  is  the  cardinal  matter, 
as  in  cancer  or  neuralgia. 

The  kinds  of  pain  are  so  numerous,  often  so  marked,  and 
usually  so  suggestive,  that  an  attempt  will  be  made  here  to 
classify  pain  in  a  practical  grouping.  '  Pain  is  the  protector 
of  the  voiceless  tissues.'  This  is  a  good  basis  for  the  super- 
structure. Say  the  ankle  is  sprained ;  if  it  were  not  for 
the  pain  produced  on  motion,  the  injured  part  would  never 
secure  the  rest  desirable  for  repair.  Or  there  is  an  ulcer  in 
the  stomach  ;  here  pain  secures  that  comparative  rest  alone 
compatible  with  the  healing  of  the  ulcer.  Then  there  is 
pain  which  serves  no  apparent  good  end,  as  the  pain  of 

14 


2IO         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

periostitis  or  of  cancer  ;  while  at  other  times,  as  in  pleurisy, 
the  pain  compels  that  quiet  which  is  favourable  for  the 
progress  of  the  case.  Or  in  stone  in  the  bladder  the  pain  pro- 
duced by  motion  teaches  the  patient  to  avoid  injury  to  the 
bladder  from  the  forcible  impact  of  the  stone.  Nor  is  pain 
always  felt  in  the  seat  of  disease;  in  hip-joint  disease  the 
pain  is  usually  felt  in  the  knee-joint ;  while  the  'shoulder- 
tip  pain  '  of  liver  disease  is  well  known.  Often  the  pain  is 
felt  in  terminal  nerve-ending,  as  in  neuralgia. 

In  inflammation  the  pain  is  accompanied  by  heat,  redness, 
and  swelling,  the  classical  association.  In  neuralgia 
the  pain  is  '  gusty,'  either  when  only  felt  at  times,  or  when, 
in  severe  cases,  there  is  always  more  or  less  pain.  Herpes 
zoster  is  a  neurosal  skin  affection  following  the  track  of  a 
nerve.  The  pain  is  burning  and  stinging.  Sometimes  the 
eruption  does  not  accompany  the  pain ;  but  the  pain  of 
lierpes  sine  eruptione  is  distinctly  stinging,  and  comes  on  in 
gusts.  In  locomotor  ataxy  the  pains  are  sudden  and 
severe,  and  have  been  called  'lightning'  pains.  While  the 
pain  of  rheumatism  is  dull  and  aching.  In  gout  the  pain  is 
sharp,  sometimes  excruciating;  as  was  the  pain  of  stretching 
ligaments  under  the  torture  of  the  rack.*  Then  the  pain 
of  cancer  is  stabbing  or  lancinating.  The  pain  of  inflamed 
serous  membranes  rubbing  on  each  other  is  acute,  and 
aggravated  by  movement.  Then  '  the  same  abnormal 
action  does  not  always  create  the  same  kind  of  pain.  In- 
flammation, for  instance,  causes  difierent  pain  as  it  involves 
different  structures;  the  pain  from  an  inflamed  pleura  is 
not  the  same  as  that  from  an  inflamed  muscle.     Speaking 

*  Perhaps  it  is  a  little  out  of  place  here,  and  yet  not  altogether,  to 
think  of  the  pain  of  the  rack.  Some  bore  the  first  racking  with  un- 
flinching courage,  but  broke  down  on  the  second  or  third  trial. 
When  we  think  of  forcible  extension  of  joints  inflamed  by  the  first 
stretching,  we  can  conceive  the  agonising  torture  inflicted  by  sub- 
sequent applications  of  the  rack ;  it  would  be  more  than  human 
nature  could  bear,  however  determined. 


THE  PATIENT'S  SENSATIONS.  211 

generally,  the  tissues  themselves  seem  to  determine  the 
form  of  pain  more  certainly  than  does  the  precise  character 
of  the  morbid  process.  Thus,  pain  in  diseases  of  the  periosteum 
and  bones,  no  matter  what  may  be  the  exact  nature  of  the 
malady, is  mostly  burning  and  constant;  in  the  serous  mem- 
brane sharp;  in  the  mucous  membrane  dull;  and  in  the  skin 
burning  or  itching.' — Da  Costa.  The  pain  of  an  injured  or 
inflamed  muscle  is  dull  and  aching,  and  aggravated  by 
movement,  i.e.,  the  contraction  of  the  fibrillre.  The  pain  of 
a  sprained  joint  is  severe  and  sickening  at  times.  In  ostitis 
the  pain  is  deep-seated^  and  the  part  is  very  tender,  while  it 
is  aggravated  at  night ;  '  and  when  the  disease  is  chronic  is 
much  influenced  by  the  weather.'  Pain  in  nerves  is  often 
tingling,  and  if  produced  by  a  blow,  is  felt  at  the  terminal 
or  peripheral  endings,  as,  for  instance,  a  blow  on  the 
olecranon  is  felt  as  tingling  in  the  little  finger-end. 
When  a  nerve  is  nipped,  as  by  a  cancerous  growth,  or  by 
pressure,  as  in  periosteal  thickening  diminishing  a  fora- 
men through  which  a  sensory  nerve  pierces  the  spinal 
column,  it  has  a  lancinating  or  stabbing  character.  The 
pain  of  an  abscess  forming  is  'throbbing;'  while  that  of 
cancer  is  characteristically  *  lancinating.'*  It  is  also  well  to 
reflect  on  some  relations  of  pain :  it  is  aggravated  by 
movement  in  joint  or  muscle;  when  osteal  it  is  'nocturnal;' 
when  connected  with  a  nerve  it  follows  the  nerve  trunk. 

Some  time  ago  a  gentleman  consulted  me  about  a  per- 
sistent pain,  at  some  times  worse  than  at  others,  at  the  outer 
edge  of  the  left  scapula,  about  the  middle.  The  first  thing 
to  note  about  it  was  that  it  was  evidently  connected  with 
one  intercostal  nerve ;  nest,  that  it  was  aggravated,  or 
relieved  by  certain  movements;  then  it  was  worse  at 
bedtime,  while  it  was  relieved  by  a  warm  bath.  (When 
the   vessels   dilate   on    the   oncome   of  sleep    any   further 

*  Cancer  produces  no  pain  in  itself  :  it  is  when  a  nerve-fibre  is 
caught  in  its  terrible  grip  that  the  pain  is  set  up. 

14—2 


212         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

tenseness  of  a  part  thereby  increases  the  pressure,  and  with 
it  the  pain ;  consequently  osteal  and  periosteal  affections 
are  worse  when  the  relaxation  of  the  vessels  leading  to 
sleep  is  set  up.  The  relaxation  of  the  cutaneous  vessels  by 
a  warm  bath  relieved  the  vascularity  of  other  parts,  and 
with  it  the  pain  of  tension.)  The  diagnosis  was  un- 
avoidable that  the  cause  of  the  pain  was  pressure  on  the 
sensory  root  at  the  foramen  where  it  emerged  from  the 
spinal  canal.  The  case  was  '  rheumatic,'  in  the  sense  that 
the  gentleman  was  liable  to  rheumatic  pains ;  but  on 
inquiry  there  turned  out  to  be  a  possible  syphilitic  taint 
dating  far  back.  I  thought  it  well  to  take  the  opinion  of 
Mr.  Jonathan  Hutchinson,  who  agreed  with  the  view  that 
the  pain  was  due  to  the  pressure  of  the  thickened  periosteum ; 
and  that  the  periosteal  mischief  was  probably  specific. 
(Relief  was  gained  by  iodide  of  potassium,  while  all  other 
treatment  previously  advised  was  futile.) 

The  relations  of  any  pain  are  worth  investigation.  Take 
lumbago,  for  instance.  It  may  be  gouty  or  rheumatic, 
and  muscular  when  motion  increases  it.  If  there  be 
periosteal  complications,  the  spinous  processes  of  the 
vertebrse  will  be  tender  on  pressure.  A  load  in  the  bowels 
would  lack  these  features.  A  renal  calculus  would  give 
unilateral  pain,  with  reflex  vomiting.  Lumbar  abscess  also 
gives  unilateral  pain,  and  has  its  own  features.  Myalgia, 
or  *  backache,'  is  found  with  debility,  and  is  much  more 
intense  on  movement,  and  relieved  by  lying  down ;  while 
lumbar  neuralgia  bears  a  relation  to  a  nerve  trunk,  and  has 
its  '  spots  of  pain.' 

Neuralgia  is  accompanied  by  these  '  spots  of  pain,'  other 
wise  termed  '  the  tender  spots  of  Valleix.'  The  '  pain  under 
the  heart,'  so  common  with  women,  is  intercostal  neuralgia, 
with  the  main  tender  spot  near  the  left  apex  of  the  heart, 
the  one  usually  complained  of;  a  second,  at  the  outer  edge 
of  the  scapula,  about  its  middle  ;  and  a  third,  where  the 
nerve  pierces  the  spine.     The  pressure  of  the  finger-tip  on 


THE  PA  TTENT'S  SENS  A  TIOXS.  2 1 3 

these   '  tender  spots '  will   usually   be   sufficient   to  cause 
!  sharp  pain.     Movement  does  not  affect  this  pain ;  while  in 
intercostal  rheumatism  the  reverse   is   the  case,  and   the 
tender  spots  are  wanting. 

Having  grasped  the  subject  of  the  varieties  of  pain  ac- 
cording (1)  to  the  tissue  affected,  and  (2)  the  nature  of  the 
affection,  the  reader  will  follow  with  more  interest  the 
description  of  some  of  the  leading  pains  complained  of  It 
may  be  well  to  start  from  the  crown  downwards. 

Headaches  are  of  various  kinds.  There  is  the  '  sick- 
headache,'  frontal  and  depressing.  There  is  the  '  occipital ' 
headache  of  venous  fulness  about  the  Torcula  Hierophili ; 
sometimes  it  is  really  neuralgia  of  the  occipital  nerve. 
Then  there  is  the  side-headache,  due  to  the  eyes  not  being  ab- 
solutely a  pair.  Also  the  face-ache,  often  involving  the  eye,  of 
a  carious  tooth.  There  is  the  nervous,  or  neuralgic  headache 
of  women,  sharp  and  short ;  and  the  true  facial  neuralgia, 
with  tenderness  of  the  supraorbital,  sometimes  the  infra- 
orbital nerve-ending.  There  is  '  hemicrania' :  may  be  peri- 
osteal with  a  syphilitic  node  at  times ;  or  it  may  be  migraine 
with  optical  disturbance  and  gastric  symptoms.  There  is 
the  pain  of  ear-disease.  The  dull  vertical  pain,  with  sense 
of  weight  and  depression,  of  cerebral  anaemia  is  very 
common  with  women ;  and  in  practice,  acquaintance  with 
'  vertical '  headache  is  very  useful.  Then  there  is  the 
'  congestive '  headache,  as  if  a  bolt  were  driven  into  the 
head,  of  vascular  fulness.  And  the  '  toxic  '  headache,  best 
known  after  alcoholic  excess.  When  the  cerebro-spinal  me- 
ninges are  involved,  then  pain  is  maddening.  The  brain  does 
not  feel '  pain,'  that  is,  physical  pain,  when  aff"ected  until  the 
meninges  are  reached,  and  implicated,  and  then  pain  is  felt; 
awful  and  excruciating  often.  It  has  been  said  (Hughlings 
Jackson)  that  frontal  headaches  are  linked  with  abdominal 
disturbances ;  vertical  headaches  with  cerebral  affections  ; 
and  occipital  headaches  with  disturbance  in  the  circu- 
lation. 


214         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

The  essentially  facial  pains  are  '  brow  ague,'  and  facial 
neuralgia.  The  last  is  usually,  or  rather  commonly,  on  the 
right  side  ;  while  intercostal  neuralgia  is  almost  always  on 
the  left  side.  As  to  the  particular  nerve-twig  affected,  it 
must  be  sought  in  each  case. 

The  pains  felt  in  the  neck  are  neuralgic,  or  from  enlarged 
glands,  or  laryngeal  affections  mainly. 

Thoracic  pains  are  commonly  a  spot  of  pain  in  the 
pectoral  muscle,  or  over  it,  sometimes  near  the  nipple, 
sometimes  near  the  sternal  attachment,  corresponding  in 
significance  to  the  spots  of  pain  at  the  back.  Then  there 
is  intercostal  pain,  spoken  of  before  (p.  212).  Sternal  pain 
may  be  osteal;  or  it  may  be  the  pain  of  angina  pectoris, 
which  may  be  a  neuralgia,  as  in  anaemic  women,  or  truly 
cardiac  in  oldish  men.  Pains  about  the  heart  bear  no 
relation  to  the  heart,  except  angina.  Disease  of  the  heart 
gives  no  pain,  except  pericarditis.  The  '  pain  of  Piorry  '  at 
each  contraction  of  the  heart  in  myocarditis  is  mythical. 
Organic  chronic  disease  of  the  heart  does  not  include 
pain  among  its  symptoms.  Then  there  is  a  sternal  pain 
often  complained  of  in  dyspepsia.  Pain,  with  weight  and 
oppression,  is  often  complained  of  in  thoracic  maladies  down 
to  a  sharp  cold. 

Thoracic  pain  at  the  back  is  often  dyspeptic ;  this  '  gives 
pain  betwixt  the  shoulders.'  Then  there  are  '  spots  of 
pain,'  chiefly  at  the  lower  edge  of  the  scapula,  towards  the 
spine,  which  can  be  *  covered  with  the  thumb-end,'  which 
are  commonly  pronounced  '  liver'  or  '  kidney,'  and  which 
are  certainly  related  to  conditions  where  the  blood  is  laden 
with  nitrogenized  waste.  Then  there  is  the  boring,  burning 
pain  in  the  spine  of  an  aneurysm  eroding  the  spinal  column, 
worst  at  night ;  and  the  lancinating  pain  of  cancer  in  the 
intervertebral  cartilages. 

Abdominal  pains  are  numerous. 

Pain  in  the  stomach  is  felt  after  food  immediately'',  and 
violently   in    gastric  ulcjr,  relieved    at    once  by  vomiting. 


THE  PATIENT'S  SENSATIONS.  215 

Then  there  is  the  pain  of  indigestion,  with  or  without 
flatulence,  which,  however,  may  be  linked  with  carcinoma. 
AVlien  felt  soon  after  a  meal,  the  body  of  the  viscus  is  pro- 
bably affected ;  if  not  till  an  hour  or  more  after  a  meal,  it 
points  to  the  pylorus,  or  the  duodenum.  Then  there  is  pain 
in  the  gall-bladder,  '  biliary  colic'  At  times  a  knuckle  of 
the  great  intestine  contains  some  flatus,  and  here  pain  is 
felt  when  the  vermicular  action  passes  over  this  knuckle ;  no 
matter  on  which  side.  Intestinal  pain  is  referred  to  the 
navel.  Whenever  '  navel  pain'  is  complained  of,  it  is  well 
to  examine  the  bowel  carefully,  even  for  an  obturator 
hernia,  '  Girdle  pains '  round  the  abdomen  tell  of  the 
spinal  meninges  being  implicated.  '  Colic '  is  spasmodic 
pain,  due  to  contraction  of  the  circular  fibre  of  the  bowel. 
It  may  be  very  severe.  Abdominal  neuralgia  is  a  true 
neuralgia  (see  p.  116).  Bowel  pain  may  be  felt  locally  from 
local  causes. 

Abdominal  pain  at  the  back  may  be  lumbago  (p.  212), 
or  be  ovarian,  or  uterine  in  origin.  Backache  may  be  one 
of  the  early  indications  of  a  specific  fever,  especially  small- 
pox. 

Pelvic  pain  in  man  is  usually  vesical.  When  due  to  a 
stone  in  the  bladder,  movement  aggravates  it.  When  a 
boy  is  suspected  to  have  a  stone  in  his  bladder,  get  him  to 
jump  down  from  a  chair ;  and  then  try  to  get  him  to  do  it 
again !  His  compliance  with  the  request  will  usually  settle 
the  diagnosis  in  the  negative.  In  stone  in  the  bladder,  and 
in  retention  from  stricture,  the  pain  is  usually  felt  in  the 
glans  penis. 

In  ureteral  colic  the  pain  is  felt  in  the  testes  and  down 
the  thigh ;  indeed,  at  the  terminal  endings  of  the  genito- 
crural  nerve. 

Pelvic  pains  in  women  are  often  suggestive.  There  is 
the  expulsive  '  bearing-down  pain'  of  constrictive  dys- 
menorrhoea,  or  of  an  enlarged,  heavy  womb.  There  is  pain 
connected  with  the  ovary.     If  lying  high  over  the  colon, 


\ 


2i6         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

pain  is  produced  by  the  act  of  defsecation ;  if  the  ovary  be 
in  frontj  the  pain  is  rather  associated  with  the  act  of 
urination.  Sometimes  the  tender  ovary  is  pained  in 
coitus ;  while  coitus  is  intensely  painful,  or  altogether 
unbearable  in  vaginismus,  or  caruncle  of  the  meatus  of  the 
urethra.  Pains  are  felt  in  the  sacrum,  and  the  coccyx,  in 
various  uterine  and  ovarian  conditions,  or  over  the  crest  of 
the  ilium  or  down  the  crural  nerve. 

Disease  in  the  hip  gives  local  pain,  aggravated  by  throw- 
ing weight  on  the  limb  ;  or  in  morbus  coxarius  may  be  in 
the  knee ;  or  there  may  be  sciatica.  The  latter  has  its 
tender  spots  when  neuralgic  ;  one  at  the  lower  end  of  the 
sacrum,  one  on  the  side  of  the  trochanter,  a  third  at  the 
head  of  the  fibula,  and  a  fourth  behind  the  outer  ankle. 

Pain  is  felt  in  the  limbs ;  and  by  attention  to  the  charac- 
ter of  the  pain,  its  relation  to  motion,  or  to  the  act  of 
sleeping,  as  well  as  its  anatomical  relations,  it  can  usually 
be  made  out  clearly  as  regards  its  causation.  Gouty  pain 
in  the  great  toe  may  be  mistaken  for  a  sprain  ;  but  it  soon 
discloses  its  real  nature. 

In  ulceration  of  the  articular  cartilages,  the  pain  is 
always  relieved  by  separating  the  affected  surfaces,  and 
increased  by  pressing  them  together.  In  hip  disease  it  is 
not  easy  to  get  the  patient  to  stamp  vigorously  a  second 
time  with  the  affected  limb. 

The  correct  interpretation  of  pain  usually  involves  thought 
— sometimes  much  thought.  Bej'ond  its  anatomical  or 
histological  recognition,  there  are  its  general  relations  ;  and 
the  following  piece  of  graphic  writing  by  the  late  Dr.  Fuller 
has  always  impressed  me  ;  and  in  the  hope  it  will  act  in  a 
similar  manner  on  my  readers,  it  shall  be  given  verbatim. 
The  subject  spoken  of  is  sciatica  : — '  If  the  patient  is  thin, 
pale,  sallow,  and  extremely  sensitive  to  atmospheric  vicissi- 
tudes ;  if  he  has  experienced  pain,  or  threatenings  of  pain, 
in  other  parts  of  the  body ;  if  at  some  former  period  he  has 
suffered  from  rheumatism  affecting  the  joints  ;  and  above 


THE  PATIENT'S  SENSATIONS.  217 

all  if  his  present  attack  is  the  result  of  exposure  to  cold  and 
damp,  the  disease  under  which  he  is  labouring  is  rheumatic, 
and  is  to  be  relieved  by  vapour-baths,  guaiacum,  alkalies, 
and  similar  remedies.  On  the  other  hand,  is  he  stout,  florid, 
and  a  free  liver,  taking  little  exercise,  sleeping  much  ;  is  he 
plagued  with  heartburn,  acid  eructations,  and  occasional 
lowness  of  spirits,  or  has  he  previously  suffered  from  gout, 
his  malady  is  of  gouty  origin ;  and  is  to  be  cured  by  col- 
chicum,  alkalies,  and  alteratives.  Again,  is  he  cachectic,  and 
out  of  health ;  has  his  throat  been  ulcerated,  or  his  skin 
disfigured  by  blotches  or  eruptions ;  has  he  taken  mercury 
or  experienced  pains  in  his  bones,  the  mischief  is  probably 
due  to  syphilitic  taint,  and  is  to  be  cured  by  sarsaparilla 
with  iodide  of  potassium.  Or  again,  is  he  robust,  and 
usually  in  the  enjoyment  of  excellent  health  ;  has  his  pre- 
sent attack  been  preceded  by  constipation  or  irregularity  of 
the  bowels,  by  flatulence,  distension,  and  crampy  pains  in  the 
abdomen ;  and  above  all,  is  it  accompanied  by  coating  of  the 
tongue  and  fcetor  of  the  breath ;  then,  if  the  disease  does 
not  acknowledge  either  of  the  origins  before  alluded  to,  it 
is  probably  due  to  irritation  of  the  sacral  plexus  of  nerves 
consequent  on  an  unhealthy  loading  of  the  intestines.  This 
opinion  will  be  confirmed  if  the  pain  be  confined  to  the 
right  leg,  for  the  disease  not  unfrequently  arises  from  un- 
healthy accumulations  of  faecal  matter  in  the  caput  coli. 
Such  a  case  as  this  is  to  be  cured  by  the  administration  of 
active  purgatives,  both  in  the  form  of  enemata,  and  by  the 
mouth,  together  with  such  other  medicines  as  are  calcu- 
lated to  carry  off  the  irritating  matter,  and  to  produce  a  more 
healthy  secretion  from  the  bowels.  .  .  .  Again,  if  the 
patient  has  never  experienced  an  attack  of  gout  or  rheu- 
matism, and  has  not  suffered  from  wandering  pains  in  the 
limb ;  if  he  is  free  from  venereal  taint,  and  has  not  been 
subjected  to  a  course  of  mercury;  if  his  bowels  have  been 
acting  regularly,  and  the  dejections  are  of  a  healthy  charac- 
ter ;  if  his  skin  is  healthy,  his  tongue  clean,  his  urine  clear, 


2 1 S         PH YSIOL OGICAL  FA  CTOR  IN  DIA  GNOSIS. 

his  pulse  normal,  and  the  appetite  and  digestion  good  ;  if, 
in  short,  there  is  an  absence  of  the  symptoms  which  indi- 
cate either  of  the  forms  of  derangement  hitherto  alluded 
to,  his  malady  is  probably  of  neuralgic  origin,  and  is  to  be 
relieved  by  tonics,  sedatives,  and  other  remedies  directed 
against  that  variety  of  derangement.'  It  is,  then,  of  moment 
to  regard  pain  in  connection  with  general  conditions,  as  well 
as  its  tissue  and  anatomical  (regional)  relations. 

One  thing,  too,  must  be  grasped  about  pain.  Any  irrita- 
tion of  a  nerve-libril  on  its  route  from  the  periphery  to  the 
centre  is  referred,  as  a  sensation,  to  its  terminal  ending.  A 
postman  in  the  North,  who  had  lost  an  arm  above  the 
elbow,  often  complained  of  his  little  finger  aching  with  cold 
on  cold  mornings.  The  cold  really  affected  the  nerve  ending 
in  the  stump,  and  was  felt — especially  in  the  fibrils  which 
ran  to  the  little  finger — long  after  the  member  itself  had 
gone.  The  term  '  phantom  limbs  '  is  given  to  these  sensa- 
tions. '  Flashes  of  pain '  over  certain  cutaneous  areas  not 
distinctly  related  to  the  distribution  of  any  particular  nerve- 
twig — at  least,  so  far  as  has  been  observed — are  found  with 
gout.  Sometimes  passing  sensations  of  heat  or  cold  are 
experienced  locally,  as  after  a  blow  on  the  sacrum,  when  one 
or  other  buttock  will  be  liable  to  be  so  affected  at  intervals, 
and  for  a  brief  period  only,  for  some  time  afterwards. 

Pain  has  relations  yet  but  imperfectly  understood,  as  '  the 
shoulder-tip  pain  ^  of  liver  trouble.  In  one  case  known  to 
me,  if  the  umbilical  boss  be  lightly  scratched  by  a  finger- 
nail, a  sharp  sting  of  pain  is  instantly  felt  at  the  centre  of 
the  upper  surface  of  the  glenoid  cavity  on  the  left  side  (the 
shoulder- tip).  It  is  no  imaginary  association,  being  experi- 
enced when  all  tliought  of  it  has  been  dormant  for  months. 

Tenderness. — This  may  exist  with  or  without  actual  pain. 
In  inflammation, '  modification  of  the  sensibility  of  the  part, 
owing  partly  to  increased  sensibility  of  the  nerves,  but 
chiefly  to  the  pressure  exercised  on  their  terminal  branches 
by  the  dilated  blood-vessels,  manifests  itself  by  the  occur- 


THE  PA  TIENrS  SENS  A  TIONS.  1 1 9 

rence  of  pain,  or  by  some  special  nervous  sensibility  of  the 
organ ;  thus,  in  the  eye,  by  the  patient  perceiving  flashes 
of  light,  and  in  the  ear  by  noises  of  various  kinds  ;  in  the 
bladder  by  a  constant  desire  to  expel  the  urine ;  and  in  the 
kidney  by  a  desire  to  urinate.' — Erichsen.  There  is,  in 
short,  an  exalted  sensibility — a  hypersesthetic  state,  probably 
due  to  the  increased  vascularity — which  gives  pain  on  slight 
excitation.  The  part,  usually  inflamed,  is  exquisitely  sen- 
sitive, and  a  slight  touch  or  movement  will  give  actual  pain, 
often  severe. 

There  are  other  general  conditions  of  much  moment  which 
may  next  be  considered,  of  which  the  two  most  important 
are  sleep  and  the  appetite. 

Sleep. — The  amount  of  sleep  natural  to  different  persons 
varies.  Broad  stout  persons  usually  require,  or  at  least 
seem  to  require,  long  hours  of  sleep.  Persons  of  thin  flank 
■with  comparatively  large  heads,  seem  to  require  only  short 
hours  of  rest.  Some  women  of  this  type  seem  almost  never 
to  sleep  when  there  is  anything  to  be  done  requiring  wake- 
fulness. Consequently,  in  estimating  the  importance,  or 
extent  of  sleeplessness  with  any  patient,  the  mere  hours  of 
sleep  must  not  alone  be  taken,  without  further  consider- 
ation. Then  there  is  a  consensus  of  opinion,  both  with 
medical  men  and  nurses,  that  patients  do  actually  sleep 
more  than  they  themselves  think,  or  will  admit.  Though, 
perhaps,  on  the  whole,  very  sleepless,  they  drop  oS"  at  times 
and  get  a  brief  nap,  of  which  they  do  not  seem  to  be  con- 
scious ;   and  which,  consequently^,  they  will  not  adniit. 

Speaking  broadly,  with  the  exception  of  coma  and  drow- 
siness (due  to  the  typhoid  state,  to  carbonic  acid  poisoning, 
to  uraemia,  and  conditions  of  cerebral  disease,  or  pressure  on 
the  hemispheres),  the  more  a  patient  sleeps  the  better:  the 
less  the  worse.  Certainly  such  is  the  case  in  acute  disease 
interfering  with  sleep.  Consequently  the  question  of  in- 
ducing sleep  artificially  requires  consideration,  and  the 
adaptation  of  the  means  to  the  end  in  all  cases. 


L 


220         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS^, 

Sleep  requires  the  condition  of  cerebral  antemia  as  a 
necessary  indispensable  factor.  Consequently  a  common 
cause  of  sleeplessness,  especially  with  women,  is  '  cold  feet.' 
The  feet,  and  much  of  the  legs,  are  chilly,  deathly  cold. 
Here  the  smaller  arteries  and  the  arterioles  are  contracted, 
and  do  not  relax.  Now,  when  sleep  comes  on  the  vessels  of 
the  rest  of  the  body  relax  (as  was  seen  in  discussing  noctur- 
nal pain,  p.  211),  and  so  the  brain  can  become  exsanguine. 
But  with  *  cold  feet '  a  large  area  does  not  relax ;  and  the 
brain,  still  full  of  blood,  cannot  go  to  sleep.  When  the 
vessels  of  the  lower  limbs  are  relaxed,  then  sleep  readily 
follows. 

Then  there  is  another  matter :  the  patient  is  drowsy, 
sometimes  painfully  so,  when  up ;  yet  when  the  head  is- 
laid  upon  the  pillow  sleep  declines  to  be  wooed.  Here 
there  is  cerebral  antemia.  "When  upright  the  blood  falls 
away  from  the  head,  the  apex  of  the  organism,  and  the  blood- 
less brain  is  drowsy.  When  the  head  is  laid  upon  the 
pillow  the  blood  flows  into  it  freely,  and  wakefulness  is  the 
result.  The  sleeplessness  of  cerebral  anaemia  is  not  at  all 
uncommon. 

Then  pain  prevents  sleep.  Pain  not  only  excites  the 
brain  hj  the  sensations  conveyed  to  it  by  the  sentient 
nerves ;  but  it  affects  the  circulation,  keeping  up  the  blood 
pressure.  (All  hypnotics  lower  the  blood  pressure  by 
relaxing  the  blood  vessels,  and  so  lower  the  action  of  the 
heart,  as  well  as  acting  upon  the  cells  of  the  cortex, 
palsying  their  energy;  and  by  this  double  effect  produce 
sleep.)  Consequently  when  the  patient  has  been  able  to 
sleep  that  fact  is  of  moment,  telling  that  the  local  cause 
of  sleeplessness  has  been  less  than  before.  A  bad  night 
usually  tells  of  a  rising  inflammation,  a  growing  abscess, 
etc. 

Then  high  temperature  is  a  cause  of  sleeplessness.  When 
blood  abnormally  warm  is  coursing  through  the  brain,  it 
excites  the   brain-cells  into  restless  activity  (the  delirium 


THE  PATIENT'S  SENSATIONS  221 

of  acute  pyrexia) ;  and  when  the  temperature  of  the  blood 
falls  the  patient  drops  asleep. 

These  relations  of  insomnia  to  pain  and  to  a  high  tempera- 
ture are  of  service  in  estimating  the  condition  of  the 
patient  from  day  to  day  when  actually  ill.  (All  hypnotics 
lower  the  temperature  by  their  effect  upon  the  circulation.) 
In  fevers  the  restless  night,  or  the  delirious  unrefreshing 
sleep  of  a  rising  pyrexia,  contrast  with  the  calm  invigorat- 
ing sleep  of  a  falling  temperature,  especially  with  a  moist 
skin.  Then  at  other  times  insomnia  is  related  to  mental 
conditions.  It  may  be  from  mental  worry,  anxiety,  or 
'  carking  care.'  Such  condition  is  well  seen  in  females  who 
are  worn  out  with  nursing  some  one,  say  a  husband,  whose 
death  has  been  the  end.  Here  they  can  do  nothing  but 
support  the  negative ;  they  can  only  negatively  oppose. 
Obstinacy  is  the  leading  mental  feature  ;  sleeplessness  their 
bodily  manifestation  of  their  condition.  The  brain  nearly 
worn  out  is  irritable,  unreasoning,  wilful,  obstinate,  and  un- 
manageable. Sometimes  actual  insanity  is  reached.  Here 
sleeplessness  is  the  measure  of  the  tax  upon  the  brain.  At 
other  times  the  waking  thoughts  refuse  to  be  put  aside,  and 
crowd  upon  the  consciousness,  each  struggling  to  the  fore- 
ground. Here  there  is  one  of  the  most  significant  indica- 
tions of  continued,  often  long  continued,  overwork. 

In  other  cases  again  the  sleeplessness  is  due  to  the 
necessity  for  voluntary  effort  to  maintain  the  respiration,  as 
seen  in  acute  disease  of  the  respiratory  organs ;  or  in  the 
dyspnoea  of  a  failing  circulation,  as  at  the  end  of  a  mitral 
case,  for  instance.  Here  the  patient  could  sleep,  and  sleep 
soundly  without  any  soporific  agent,  if  only  the  necessity 
for  breathing,  the  accumulation  of  carbonic  acid  in  the  blood 
stimulating  the  respiratory  centre,  was  done  away  with. 
The  patient  begs  for  sleep,  and  if  the  request  leads  to  a 
narcotic  being  given  (on  the  impression  that  it  is  indicated), 
the  voluntary  efforts  are  arrested  and  the  patient  sleeps — to 
wake  no  more.     There  are  few  more  painful  experiences 


222  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

among  the  many  furnished  by  a  medical  career,  than  the 
sight  of  a  patient  worn  out  for  want  of  sleep  piteously 
begging  for  a  sleeping  draught,  whose  request  must  be 
sternly  refused ;  or  the  victim  of  carbonic  acid  poisoning, 
waking  up  in  alarm  from  a  hideous  dream,  sleepy  beyond 
measure,  yet  fearing  to  give  way  to  sleep — for  that  hideous 
incubus  is  sure  to  come  again  ! 

Under  all  the  circumstances  given  here,  to  find  the  sleep, 
as  differentiated  from  a  comatose  condition,  increasinor  is  a 
good  sign,  and  matter  for  congratulation.  Some  persons 
object  to  sleep  artificially  procured,  as  less  refreshing  than 
natural  sleep.     Quite  so  ;  but  better  that  than  none. 

A  minor  condition  of  sleeplessness  is  often  due  to  an 
empty  stomach.  Some  food  late  on,  with  that  demand  for 
blood  in  the  abdomen  which  food  in  the  stomach  brings, 
will  usually  win  the  capricious  goddess  Sleep.  In  many 
cases  of  invalids  and  persons  not  strong,  sleeplessness  means 
no  more  than  this.  At  other  times,  sleeplessness  is  due  to 
a  cold  bed  preventing  that  relaxation  of  the  arterioles  which 
is  requisite  to  sleep. 

Then  there  is  the  opposite  condition,  of  drowsiness.  Here 
quite  commonly  the  complaint  is,  '  I  sleep  ever  so  much ; 
yet  the  more  I  sleep  the  more  I  want  to  sleep.'  Here  there 
is  rarely  more  than  a  need  for  sleep  ;  and  if  the  craving  be 
complied  with,  the  condition  is  sooner  or  later  relieved. 
There  is  a  popular  impression  that  it  is  physically  injurious, 
and  morally  blameworthy,  to  sleep  during  the  day.  Cer- 
tainly laziness  need  not  be  encouraged  ;  but  in  the  present 
day,  too  little,  rather  than  too  much  sleep  is  the  mistake 
committed.  Drowsiness  is  a  symptom  of  cerebral  antemia 
then. 

But  at  times  it  is  significant  of  deficiency  of  arterial 
blood  with  excess  of  venous  blood  ;  the  drowsiness  of 
carbonic  acid  poisoning,  as  in  heart  failure ;  or  it  may  be 
coma  coming  on  from  uraemia,  or  from  an  enlarging  clot,  or 
sunstroke.     '  Dead-drunk'  is  not  the  sole  cause  of  drowsi- 


I 


THE  PA  TIENT  'S  SENSA  TIONS.  223 

ness  deepening  into  coma.  At  other  times  it  is  seen  as  a 
form  of  apoplexy,  or  acute  cerebral  anaemia,  coming  on  quite 
suddenly.  Here  we  can  scarcely  call  the  state  sleep ;  and 
yet  it  is  '  sleep,'  an  unconscious  condition  of  the  brain.  A 
similar  condition  of  acute  cerebral  anaemia  is  that  of  syn- 
cope from  arrest  of  the  action  of  the  heart.  *  Coma  vigil,' 
or  waking  coma,  is  often  seen  with  children,  and  is  ever  of 
evil  omen. 

Bearing  all  this  in  mind,  it  is  well  on  entering  a  sick- 
room to  inquire  what  kind  of  a  night  the  patient  has 
passed.  The  answer  given  will  often  supply  a  direction  for 
other  inquiries  and  observations.  In  all  ordinary  illnesses 
a  good  night  is  cause  of  satisfaction  ;  and  returning  sleep 
tells  of  returning  health  and  strength. 

Having  inquired  about  the  sleep,  the  next  everyday 
matter  is  to  ask  after  the  appetite. 

The  Appetite. — 'This,  too,  varies  greatly  with  different 
persons.  Females  as  a  rule  eat  less  than  men ;  certainly 
less  at  once,  and  therefore  at  shorter  intervals.  This  is  a 
matter  not  to  be  forgotten.  Remember  what  was  said 
about  the  large  and  small  tender  (p.  106).  Growing  children 
usually  have  a  good  appetite.  In  the  onset  of  acute 
maladies  the  appetite  disappears  to  return  again,  often 
vigorously,  on  convalescence.  After  acute  fever,  the  appetite 
is  often  simply  voracious.  This  is  normal  '  bulimia.'  Then 
there  is  the  bulimia  of  muco-enteritis,  and  of  some  cases  of 
phthisis  (p,  110),  which  is  morbid ;  and  here  the  craving  is 
not  of  good  omen.  An  unusual  appetite  may  be  the  pre- 
cursor of  an  attack  of  gout,  or  even  a  fit  of  epilepsj-.  A 
form  of  bulimia  as  persistent  hunger,  was  called  of  old  'the 
wolf  at  the  stomach ;'  which  probably  depends  upon  some 
disordered  state  of  the  upper  portion  of  the  alimentary 
canal.  As  thirst  is  felt  in  the  fauces,  hunger  is  felt  in  the 
epigastrium. 

Anorexia,  or  loss  of  appetite,  marks  all  febrile  conditions. 
Then  it  is  lost  in  maladies  preying  on  the  mind.     A  loath- 


224         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

ing  of  food  is  experienced  as  an  indication  of  some  neurosal 
disturbance  in  women  of  the  nervous  temperament ;  while 
entire  abstinence  from  food  is  practised,  or  rather,  affected 
to  be  practised,  by  impostors,  usually  young  females,  as 
seen  in  the  Welsh  fasting-girl's  case :  when  warm  in  bed  so 
as  to  need  little  fuel  to  maintain  the  body  temperature,  it 
is  astonishing  what  small  quantities  of  food  will  sustain 
life.  (The  same  is  seen  in  shipwrecked  mariners  in  the 
tropics ;  while  in  cold  regions  the  body-temperature  would 
soon  fall  below  the  point  compatible  with  life.)  In  wasting 
illnesses  the  appetite  will  often  fail  some  time  before  death. 
First,  solid  food  is  refused,  then  fluids  are  declined;  and  soon 
after  the  patient  dies  exhausted.  About  ten  days  is  the 
store  of  food  the  organism  carries  within  it;  and  this  is 
about  the  time  patients,  slowly  sinking,  will  survive  after 
all  food  is  refused,  and  only  a  little  wine  or  brandy-and- 
water  accepted ;  much  depending  on  the  bodj'^-temperature 
and  the  surrounding  temperature,  and  not  a  little  on  the 
family  peculiarities ;  some  finding  it  much  harder  to  die 
than  others.  This  last  was  marked  in  a  family  where  I 
attended  the  mother,  over  ninety  ;  she  simply  '  failed,'  and 
took  her  bed,  and  slowly  died.  The  day  before  her  death 
she  made  her  servant  search  the  pillow  for  '  pigeon's 
feathers :'  there  being  a  superstition  that  '  the  parting' 
cannot  be  accomplished  if  there  are  pigeon's  feathers  mixed 
with  the  ordinary  feathers  of  bed-furniture.  Years  after- 
wards, her  son,  long  an  invalid,  caught  bronchitis  in  a 
London  fog,  and  resigned  himself  to  die.  But  he  did  not 
tind  this  so  easy ;  and  some  days  after  his  ordinary  medical 
attendant  had  looked  for  dissolution,  he  made  an  effort  to 
struggle  again,  and  tried  to  take  some  food  ;  but  in  vain. 
Altogether,  he  lived  ten  daj^s  after  his  medical  man,  who 
had  known  him  intimately  for  many  years,  expected  his 
death  hourly.  From  my  experience  of  his  mother,  my 
view  was  more  correct  as  to  how  long  he  would  hold  out. 
When  a  patient  is  ill,  the  sleep,  the  appetite  too,  and  to  a 


THE  PATIENT'S  SENSATIONS.  225 

less  extent  the  tone  of  voice  and  the  grip  of  the  hand,  are 
matters  to  be  carefully  noted ;  and,  if  so  noted,  will  give 
valuable  information. 

[The  youthful  reader  will  excuse  my  here  drawing  his 
attention  to  the  mental  attitude  of  the  patient,  and  the 
patient's  friends.  From  their  experience  they  have  formed 
their  opinion  of  what  is  to  be  expected  from  a  medical  man. 
They  have  seen  old  practitioners  go  carefully  over  such  mat- 
ters as  the  kind  of  night  passed;  the  appetite,  the  bowels; 
the  urine,  inspecting  the  dejecta  and  the  urine  at  times  :  and 
the  friendsexpect  all  this,  and  not  unreasonably, from  younger 
practitioners.  The  omission  of  attention  to  these  details  will 
not  only  deprive  the  medical  man  of  much  useful  information, 
but  it  may  further  deprive  him  of  the  confidence  of  those 
connected  with  the  patient ;  and  though  that  is  merely  a 
source  of  annoyance — perhaps  not  always  that  in  hospital 
practice — it  becomes  a  very  different  matter  with  private 
patients.  And  when  the  patient  can  take  a  little  food,  a 
brief  but  judicious  allusion  to  the  food  to  be  taken^  its 
character  and  amount,  is  not  time  thrown  away.  The  suc- 
cessful man  is  the  man  who  knows  human  nature  as  well 
as  his  profession — who  can  estimate  what  is  going  on  in  the 
minds  of  others,  as  well  as  be  conscious  of  the  workings  of 
his  own  mind.] 

There  are  two  matters  psychical  which  the  experienced 
practitioner  learns  to  value,  and  which  may  now  be  men- 
tioned as  affectino:  the  diasjnosis — that  is,  the  diagnosis  not 
of  the  malady  so  much  as  the  estimate  of  the  prospects  of 
the  individual ;  an  essential  part  of  the  diagnosis. 

Temperament. — This  is  often  a  factor  in  a  case  too  little 
calculated.  There  is  the  sanguine,  elastic  temperament 
which  rebounds  after  the  depression  of  illness  with  much 
energy,  giving  a  rapid  and  satisfactory  convalescence.  While 
on  the  other  hand  there  is  a  languid,  lethargic  temperament, 
where  the  patient  readily  goes  down  under  the  blow  of  disease, 
but  is  very,  very  slow   indeed  in  getting  up  again.     This 

15 


\ 


226         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

last  class  '  make  no  fight' under  serious  disease,  and  sink 
under  a  malady  the  first  class  would  probably  throw  off 
successfully.  The  same  amount  of  disease  will  be  fatal  in 
the  one  case,  but  be  recovered  from,  in  all  probability,  in  the 
other.  Experience  teaches  the  painstaking  observer  to  dis- 
criminate these  two  classes,  and  to  be  guided  thereby  in 
prognosis  both  as  to  the  probability  of  recovery  in  the  first 
place,  and  the  length  of  time  requisite  for  recovery  in  the 
second  place.  In  making  the  estimate  of  the  psychical 
factor,  the  life  history  of  the  individual  must  be  taken  into 
the  calculation.  For  instance,  some  months  ago  I  was  called 
into  consultation  on  the  case  of  a  suburban  butcher's  wife. 
She  had  some  consolidation  at  the  right  base  of  no  great 
extent,  yet  her  ordinary  medical  attendant  was  very  anxious 
about  her — an  anxiety  quite  shared  in  by  myself  on  seeing 
her.  She  was  a  woman  of  no  nervous  energy,  and  she  had 
no  mental  resources  ;  her  life  had  been  spent  in  chatting  to 
the  customers  and  keeping  the  accounts  in  the  shop.  Taken 
away  from  this  environment,  life  had  no  interest  for  her. 
She  lacked,  too,  the  mental  stimulus  of  motive,  often  a  large 
factor  in  illness.  She  was  passive — nay,  impassive  ;  and  it 
was  only  too  clear  she  would  go  down  under  the  disease 
without  a  struggle  (which  she  did). 

Lack  of  nerve-power — especially  when  combined  with 
lack  of  mental  resources — is  ever  of  bad  omen ;  and  to  be 
allowed  for  in  the  estimate  of  the  amount  of  danger  to  life 
involved  in  any  case.  There  is  the  mental  constitution  as 
well  as  the  bodily  constitution  to  be  estimated  in  the  calcu- 
lation of  the  patient's  prospects.  Closely  allied  to  this  is 
the  amount  of  courage  possessed  by  the  patient.  Where 
the  fear  of  death  is  great,  the  danger  is  increased  by  the 
patient's  anxiety ;  while  a  calm,  unemotional  attitude  is 
favourable  to  recovery.  Still  more  propitious  is  the  attitude 
of  a  strong  motive  to  live.  Under  this  last,  persons  will 
rally  and  recover  from  the  gravest  conditions  (compatible 
with  recovery)  in  a  manner  truly  wonderful  at  times.  Some 


THE  PATIENTS  SENSATIONS.  227 

people,  in  plain  English,  wony  themselves  to  death ;  while 
others  seem  to  put  death  behind  them  by  an  effort  of  will. 
The  elastic  tempei-ament  cai-ries  with  it  a  widely  different 
prognostic  association  than  that  which  attaches  to  a  languid, 
listless,  hopeless  temperament. 

Then  there  is  also  the  question  of  temperament  as  regards 
the  obeying  of  instructions.  In  many  cases  the  prospect 
is  profoundly  influenced  by  the  attention  paid  to  the 
instructions  given ;  provided  those  instructions  themselves 
are  wise.  Take  a  case  of  recent  dilatation  of  the  heart,  for 
instance ;  the  medicinal  treatment  will  produce  a  good 
result,  quickly  or  tardily,  according  as  the  patient  keeps 
quiet  and  gives  the  enfeebled  heart  rest,  so  that  it  may 
recover  itself.  In  a  hospital,  where  the  patient  can  be  made 
to  stay  in  bed,  the  case  probably  makes  a  brilliant  recovery. 
In  private,  if  the  patient  be  careless,  or  headstrong,  or  im- 
prudent, the  recovery  will  be  much  slower.  Temperament, 
as  concerned  with  obedience  to  orders,  is  a  very  consider- 
able factor  in  diagnosis  as  involving  prognosis.  In  my  own 
note-book,  the  prognosis  given  is  often  this:  'Favourable, 
if  the  patient  does  as  bid.'  And  obedient  patients  usually 
obtain  their  reward  ! 

Some  little  time  ago,  a  patient  presented  herself  with 
slight  threatenings  of  phthisis.  The  disease  in  itself  was 
nothing;  yet  the  prospect  of  the  case  was  clearly  very 
gloomy,  for  there  was  a  terribly  low  nervous  system — the 
patient  was  merely  an  animal.  She  was  advised  to  keep 
very  quiet,  and  go  to  a  retired  place  by  the  seaside.  Within 
a  week  she  went  to  a  ball,  danced  over  twenty  dances,  and 
was  preparing  to  get  married.  It  was  not  difficult  to  see 
what  the  end  of  this  case  would  be  before  long. 

Something  too  depends  upon  the  temperament  of  the 
medical  man.  One  man  whispers  hope,  while  another 
brings  despair  to  his  patients.  Few  successful  practitioners 
belonof  to  the  latter  class.  A  weak  man  hesitates  in  eraer- 
gencies  ;  a  thoughtless  man  acts  precipitately  ;  the  result  is 

15—2 


228  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

disaster  ia  either  case.  A  resolute  medical  man  usually 
communicates  something  of  his  own  mental  attitude  to  his 
patient.  A  calm  unemotional  man  will  often  'pull  the 
patient  through '  by  dint  of  his  own  character.  It  is  bad 
enough  for  a  patient  to  feel  that  he,  or  often  she,  is  going  to 
die,  without  the  doctor's  face  indicating  the  same  opinion  in 
him.  There  are  persons  who  should  never  be  allowed  to 
enter  a  sick  room  ;  their  presence  is  murderous.  Others 
again,  cheerful  and  bright,  breathe  life  into  sick  persons. 
The  temperament  of  the  nurse  or  attendants  is  far  from  un- 
important in  many  cases.  All  these  apparently  little 
matters  the  prudent  medical  man  will  take  into  calculation 
when  appraising  the  prospects  of  a  patient. 

Linked  with  the  matter  of  temperament  comes  that  of  the 
patient  feeling  ill  or  well :  better  or  worse.  The  posterior 
lobes  of  the  cerebral  hemispheres  are  linked  with,  or  related 
to,  the  systemic  condition.  When  all  is  well  the  sub- 
jective sensation  is  that  of  'feeling  well;'  when  'out  of 
sorts,'  or  '  feeling  poorly,'  there  is  something  wrong,  some- 
where. Next  to  the  questions  as  to  the  sleep  and  the 
appetite  comes  that  of  'How  do  you  feel  to-day?'  The 
answer  tells  much,  often  very  much  in  acute  disease.  In 
chronic  affections  the  condition  varies ;  one  day  the  patient 
feels  very  well,  another  day  not  so  well.  The  feelings  are  of 
importance  when  deciding  upon  what  to  do ;  as_,  for  instance, 
whether  the  patient  should  sit  up  a  while,  or  go  out  for  a 
drive,  or  walk.  These  matters  may  seem  unimportant  to 
the  man  fresh  from  the  hospital,  where  experienced  persons 
decide  such-like  matters,  without  saying  much  about  them ; 
but  they  are  far  from  unimportant  in  private  practice.  In- 
deed, quick  apprehension,  or  judicious  conduct  gained  by 
experience,  will  often  keep  a  case  doing  well,  which  other- 
wise might  end  in  disaster.  It  is  of  little  use  for  a  ship  to 
survive  the  storm  to  be  wrecked  at  the  mouth  of  the 
harbour  by  injudicious  steering. 

In  that  department  of  diagnosis  which  deals  with  the 


THE  PATIENTS  SENSATIONS.  2:9 

amount  of  danger  to  life  involved  in  any  case,  either  acute 
or  chronic,  much  depends  on  '  tlie  personal  equation  '  of  the 
medical  man.  One  is  hopeful  and  sanguine,  another  inclined 
to  take  a  gloomy  view  of  every  case  :  so  will  be  their  prog- 
nosis. A  very  eminent  and  excellent  physician,  who  was 
himself  the  subject  of  grave  valvular  disease  of  the  heart, 
came  to  take  the  worst  possible  view  of  many  cases  ;  he 
seemed  indeed  to  transfer  the  gloomy  prospect  of  his  own 
case  to  the  opinion  he  formed  of  the  cases  of  his  patients. 
Here  the  intellect  was  warped  by  disease.  It  is  human  to 
err ;  and  err  we  must  in  our  opinions  as  medical  men  at 
times.  Of  the  two  directions  it  is  probably  better  for  all  if 
the  medical  man  err  a  little  on  the  sanguine  side.  Re- 
member, too,  the  prognosis  may  influence  the  result.  If 
all  breathes  hope,  the  patient  will  have  a  far  better  prospect 
than  where  a  serious  gloom,  the  shadow  thrown  forward  of 
funereal  solemnity,  pervades  the  mental  atmosphere.  Very 
often  the  doctor's  voice  and  countenance  give  the  key-note 
to  all.  Cheeriness  is  an  excellent  quality  for  a  medical  man  ; 
nor  is  it  either  necessary  or  desirable  to  lay  it  aside  and  put 
on  an  air  of  deep  gravity  when  entering  the  bedroom  in  a 
hopeless  case  very  often.  The  air  of  an  undertaker  is  not 
that  required  by  a  medical  man;  by  sensible  persons,  at 
least. 


CHAPTER  XII. 

THE    PATIENT   IN   HIS   BEDROOM. 

Some  years  ago,  in  a  conversation  with  a  medical  brother  of 
some  experience,  the  subject  cropped  up  of  the  behaviour  of 
the  medical  practitioner  in  the  sick-room,  when  he  said  : 

'  Yes,  what  a  pity  it  is  that  the  demeanour  in  the  sick- 
room is  not  more  studied  by  young  practitioners  !  I 
remember  well  when  a  distinguished  graduate  of  the  London 
University  settled  among  us,  a  number  of  us  were  delighted 
to  have  a  neighbour  to  call  in  who  could  help  us  in  some 
matters,  not  taught  in  our  college  days,  in  certain  difficult 
cases.  He  had  the  knowledge  too,  but  the  scheme  was  a 
failure.  He  was  not  familiar  with  the  sick-room,  and  the 
friends  of  the  different  patients  at  once  noted  this ;  they 
could  judge  of  that,  and  measured  him  accordingly.  Of 
course,  they  could  not  estimate  his  knowledge.'  The  conver- 
sation sank  down  into  my  mind,  feeling  how  true  this  was, 
that  the  friends  could  only  estimate  the  man  by  some  test 
known  to  them ;  and  how  unfortunate  it  was  that  the 
man's  real  worth  was  so  unhappily  handicapped.  Since 
then  my  advice  to  young  men  on  entering  practice  has  still 
more  decisively  taken  the  direction — '  Spend  a  couple  of 
years  as  assistant  with  a  man  in  good  practice,  and  learn  to 
be  familiar  with  private  patients.  Do  not  make  your  in- 
evitable mistakes  where  you  mean  to  settle  ultimately  !' 

Some  have  taken  the  advice;  others  have  not  been  able 
to  realize  how  they  could  possibly  require  any  such  train- 


I 


THE  PATIENT  IN  HIS  BEDROOM.  231 


ing ;  making  a  mistake  with  them  seemed  quite  out  of  the 
question.  Yet  it  is  to  be  feared  they  have  not  been 
exempt  from  the  common  lot  of  frail  humanity.  In  the 
belief  that  this  aspect  of  entering  practice  is  one  not 
sufficiently  studied,  and  that  many  a  promising  man  wrongs 
himself  by  the  neglect  thereof,  the  subject  will  be  carried 
a  little  farther  ;  as  it  has  clearly  to  do  with  his  usefulness. 

Some  time  ago  I  asked  two  young  medicos,  each  having 
been  a  resident  house-surgeon,  the  following  question  : 
'  Suppose  you  were  visiting  an  old  gentleman  of  about 
sixty  years  of  age,  who  is  recovering  from  a  sharp  attack  of 
bronchitis,  and  can  sit  up  about  three  hours  a  day  ;  you 
find  him  wrapped  in  blankets  in  his  arm-chair,  and  a  sharp- 
looking  old  lady  reading  the  newspaper  to  him.  What  will 
you  ask  V  Each  got  so  far  as  to  ask,  '  How  are  you  to- 
day ?'  One  got  a  step  further :  '  How  is  your  cough  V 
Then  the  interrogation  ceased — the  well  of  inspiration  dried 
up  !  Yet  neither  were  fools  ;  they  were,  in  my  opinion, 
fair  average  specimens  of  the  young  hospital  medico  con- 
templating private  practice.  When  asked  what  they  would 
do,  with  the  greatest  alacrity  they  declared  they  '  would  have 
up  his  shirt,  and  examine  the  backs  of  both  bases '  (lung). 
Now  this  of  course  would  be  hospital  practice;  to  neglect  to 
do  so  would  be  to  run  the  risk  of  a  '  wigging '  from  the 
visiting  physician.  '  What !'  I  asked,  '  with  the  old  lady 
sitting  there  V  Neither  seemed  to  take  the  old  lady  into 
account  at  all ;  that  part  of  my  question  was  quite  super- 
fluous, apparently.  Both  looked  a  little  taken  aback  at 
their  want  of  gallantry  in  overlooking  the  old  lady.  In 
actual  practice  that  old  lady  could  not  be  safel}'  ignored. 
She  had  seen  lots  of  doctors  before  ;  was  there  to  form  her 
opinion  about  the  new  doctor,  as  one  factor  in  her  presence 
there,  in  all  probability.  They  are  both  in  good  practice 
now,  and  quite  recognise  two  things :  (1)  that  old  ladies 
are  not  to  be  ignored ;  and  (2)  that  an  old  gentleman  who 
is  scant  of  breath  does  not  want  to  be  disturbed  out  of  his 


232         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

chair  and  his  blankets,  and  have  his  back  chilled,  without  a 
very  good  reason  for  it !  If  there  be  some  strong  reason  to 
suspect  mischief,  as  a  rise  in  the  respirations,  then  some- 
thing will  probably  be  found  to  justify  the  examination. 
But  if  nothing  be  found,  the  old  gentleman  and  the  lady 
would  probably  criticise  the  doctor  in  no  very  friendly  spirit. 
The  young  practitioner  may  depend  upon  it,  it  is  a  good 
maxim  in  practice  about  giving  a  patient  some  discomfort, 
^Don't  look  for  something  unless  you  are  pretty  sure  you  will 
find  it!'  If  there  is  nothing  to  be  found,  then  you  look, 
in  the  eyes  of  others,  as  if  you  did  not  know  your  business; 
unless  you  have  previously  said  you  did  not  expect  to  find 
anything — and  in  that  case,  why  disturb  the  patient's  com- 
fort ?  If  you  have  a  fidgety  patient,  particularly  a  doctor 
himself,  it  might  be  necessary  to  examine  the  back  to 
assure  him  there  is  nothinor  oroiuo:  on  there. 

With  these  preliminary  remarks,  the  subject  matter  proper 
of  this  chapter  may  be  discussed. 

First  note  whether  the  patient  is  in  bed,  or  up.  If 
the  latter,  if  he  is  in  his  chair,  and  how  he  looks — 
whether  at  ease,  or  not.  Then  listen  to  his  voice,  and  take 
in  its  timbre.  Shake  hands  with  him,  and  take  a  note 
of  the  grip.  Not  onl}^  should  this  be  done  on  being  first 
introduced  to  the  patient ;  but  it  is  well  to  note  all  on  each 
subsequent  visit.  If  the  voice  be  fairly  strong  and  steady, 
and  the  grip  be  firm,  so  as  to  be  distinctly  felt,  the  patient 
is  clearly  not  sinking ;  however  alarmed  about  him  his 
friends  may  be.  If,  on  the  other  hand,  the  patient  be 
listless,  speaks  with  difficulty,  and  the  hand  is  languid  and 
limp,  the  condition  is  grave ;  no  matter  what  the  malady. 
Should  the  patient  be  lying  on  his  back  in  the  middle  of 
the  bed,  with  a  vacant  countenance  and  sordes  on  his 
lips,  taking  no  notice  of  your  entry,  the  probability  is  he  is 
actually  dying — unless  it  be  a  case  of  acute  fever.  The 
old  practitioners  take  in  these  different  conditions  at 
a  glance:  but  it  is  an  educated  olance ! 


THE  PA  TIENT  IN  HIS  BEDROOM.  233 

Then  if  the  patient  bo  sittiog  up  in  bed,  breathing  with 
■difficulty,  there  is  serious  thoracic  disease  present ;  unless  it 
be  some  abdominal  fulness  preventing  the  descent  of  the 
diaphragm.  The  attitude  assumed  is  worth  noting.  There 
may  be  a  distinct  reason  for  his  lying  upon  one  side :  on  the 
right  side  with  an  enlarged  liver,  on  the  left  side  (proba- 
bly) with  a  pleuritic  effusion.  Remember  what  has  been 
said  before  (p.  70) ;  the  upper  side  of  the  thorax  is  '  the 
working  side  '  when  a  patient  is  in  the  recumbent  posture  ; 
and  there  must  be  some  strong  reason  of  some  kind,  be  it 
what  it  may,  for  it,  if  the  upper  side  is  extensively  diseased 
(or  the  thoracic  space  of  the  upper  side  much  impaired). 

Then  often  the  accessor}^  muscles  of  respiration  in  the  neck 
can  be  seen  playing  vigorously,  while  the  abdominal  character 
of  the  respiration  is  clear  through  the  bedclothes,  as  in  ex- 
tensive emphysema.  To  note  these  different  matters  is  to 
learn  much  about  the  patient's  malady ;  as  well  as  the 
extent  to  which  he  is  ill. 

Then  take  a  note  of  the  manner  in  which  the  patient 
speaks.  If  the  respiration  be  greatly  embarrassed,  the 
patient  will  'take  a  breath'  before  attempting  to  speak; 
while  utterance  will  be  perpetually  arrested  in  order  to 
breathe.  In  cerebral  exhaustion,  whether  acute  or  chronic, 
the  utterance  is  slow  and  deliberate.  Sometimes  the 
patient  affects  to  be  much  worse  than  he  or  she  actually  is, 
and  then  the  speech  is  very  suggestive  ;  it  becomes  often 
quite  an  effort  to  speak,  and  the  eye  notes  that  the  features 
do  not  tell  of  such  utter  exhaustion.  The  evidence  fur- 
nished to  the  ear  and  the  eye  does  not  tally.  Often,  too,  the 
firm  feel  of  the  hand  contrasts  with  the  languid  grip.  Once 
put  on  his  guard,  the  practitioner  can  feel  his  way. 

If  there  is  a  cough,  take  an  observation  of  it.  The  rales 
of  bronchitis  can  often  be  heard  when  the  phlegm  is  loose, 
and  comes  up  readily.  At  other  times  the  patient  sinks 
back  exhausted  after  expectorating  a  little  pellet  of  phlegm  ; 
while  the  phthisical   patient  has  paroxysms  of  coughing, 


234  PHYSIOLOGICAL  FACTOR  LW  DIAGNOSIS. 

usually  leaving  Lira  also  exhausted,  and  with  the  face 
bedewed  with  sweat.  In  pulmonary  vascular  congestion 
there  is  a  dry  cough^  as  in  mitral  disease. 

When  there  is  abdominal  pain,  there  is  a  frown  upon  the 
brow;  when  the  pain  is  severe  at  times,  there  is  a  twitch 
upon  the  features  (p.  IG). 

In  rheumatic  fever  the  patient  gives,  vividly  often,  the 
impression  of  helplessness,  lying  with  a  look  of  resignation 
on  the  face  ;  while  the  arms  show  swollen  wrists  and  hands^ 
stiff  and  useless. 

In  phthisis,  the  patient's  eye  will  often  follow  everything 
that  is  going  on  in  the  room  with  quick  restless  gaze. 

When  the  head  is  affected,  it  is  either  rolled  about  or 
held  betwixt  the  hands  ;  often  a  damp  cloth  is  seen  over 
the  forehead,  but  this  is  more  common  with  sick-headache 
than  with  actual  disease,  as  meningitis. 

When  the  patient  is  very  ill,  he  is  usually  subdued. 
When,  then,  the  patient  is  fretful  and  irritable,  constantly 
finding  fault  and  complaining,  either  he  is  not  gravely  ill, 
that  is,  not  in  immediate  danger,  or  he  is  convalescing  ; 
two  indications  that  are  worth  remembering  in  connection 
with  convalescence.  When  the  patient  is  struggling  with 
the  malady,  he  is  too  absorbed  to  reflect  on  his  feelings ;. 
but  when  the  corner  is  turned,  he  begins  to  feel  how  ex- 
hausted he  is,  and  his  constant  complaint  is  how  tired,  or 
weary  he  feels.  When,  then,  the  patient's  complaint  takes- 
this  direction,  it  usually  tells  that  the  battle  is  won — so  far. 
The  next  is  this :  when  very  ill,  he  takes  what  is  given  him 
quietly,  or  rejects  it  with  a  significant  gesture  ;  but  when 
the  patient  begins  to  criticise  his  food,  especially  in  a  hostile 
spirit,  it  tells  that  he  is  no  longer  either  struggling  for  life, 
or  feeling  exhausted  ;  but  is  once  more  strong  enough  to 
wrangle. 

There  are  some  other  matters  also  to  be  noted.  For 
instance,  the  patient  may  be  motionless,  as  after  a  stroke, 
or   in  ursemia,  or  perhaps  asleep  ;    but  it  will  be  an   ab- 


THE  PATIENT  IN  HIS  BEDROOM.  235 

normal  sleep  that  does  not  yield  to  the  entrance  of  a  medical 
man,  especially  if  it  be  his  first  visit.  Or  the  patient  may 
be  seen  with  gouts  of  blood  near  the  mouth  from  hemo- 
ptysis, which  returns  with  every  attempt  to  speak,  or  only 
on  cough  in  slighter  cases;  or  he  may  be  in  apparent 
collapse  from  hsematemesis.  Here  what  the  eye  takes  in 
is  quite  as  valuable  diagnostically  as  anything  that  may  be 
elicited  by  questions,  or  gleaned  by  physical  examination ; 
indeed,  in  haemoptysis  and  hsematemesis  the  less  of  this  last, 
perhaps,  the  better. 

Then  there  is  '  tlie  typhoid  condition,'  thus  graphically 
described  by  Tweedie : 

'It  is  announced  by  the  decline  of  the  previous  more 
acute  symptoms ;  by  the  pulse  becoming  more  rapid  and 
soft,  the  tongue  dry  and  brown,  tremulous,  and  protruded 
with  diflSculty ;  by  the  incrustation  of  the  teeth  with 
sordes  ;  by  the  increasing  intellectual  disorder,  indicated  by 
the  more  constant  low  muttering  delirium,  and  the  greater 
insensibility  and  deafness  ;  and  by  the  condition  of  the 
muscular  system,  evinced  by  muscular  tremor,  and  sub- 
sultus  tendinum,  and  in  some  cases  irregularity  or  inter- 
mission of  the  pulse,  by  the  patient  lying  sunk  on  his 
back,  or  sliding  to  the  foot  of  the  bed,  the  muscles  being 
unable  to  support  the  body  even  in  the  horizontal  position.' 
About  the  last  he  says  :  'The  prognosis  may,  in  some  mea- 
sure, be  formed  from  the  posture  of  the  patient.  When  an 
individual  labouring  under  fever  is  able  to  change  his  posi- 
tion, and  to  retain  it  for  any  length  of  time,  it  is  a  favour- 
able circumstance,  showing  that  a  degree  of  muscular 
vigour  still  remains,  and  that  the  powers  are  not  unduly 
©ihausted.^ 

/  On  the  other  hand,  if  the  patient  have  slept  and  be  easily 
/roused  ;  if  the  eye  brighten,  and  the  countenance  recover  its 
expression  ;  if  the  tongue  be  cleaner  or  moister ;  if  the  skin 
be  moist  with  a  warm  general  perspiration,  then  the  patient 
is  improving. 


236         PII YSIOL 0 GICA L  FA  CTOR  IN  DIA  GNOSIS. 

And  what  is  said  here  of  '  the  typhoid  condition'  applies 
to  conditions  of  '  urgemia.'  Whenever  a  high  temperature 
is  maintained  for  some  time,  the  nitrogenized  tissues  melt 
down,  and  then  the  typhoid  state  follows.  Old  physicians 
talked  of  maladies  '  turning  to  typhus  fever/  an  expression 
yet  heard  at  times;  what  is  really  to  be  understood  is  a 
typhoid  condition  becoming  developed,  from  the  kidneys 
being  overwhelmed  by  the  amount  of  nitrogenized  waste 
in  the  blood. 

This  involves  a  matter  upon  which  a  few  words  may 
be  said.  It  has  been  just  alluded  to  at  p.  160,  and 
that  is,  the  consequences  of  a  sustained  high  temperature. 
Under  it  the  tissues  melt,  and  especially  muscular  fibre. 
The  fibrillse  lose  their  strife,  and  become  waxy  cylinders, 
with  a  tendency  to  break  up  into  mere  debris.  Nor  is  this 
a  pathological  change  found  only  in  the  dead ;  by  the  har- 
pooning of  muscles  it  has  been  demonstrated  to  occur  in 
those  who  survive,  and  get  well.  The  consequence  of  this 
tissue- wasting  is  that  a  large  quantity  of  nitrogenized  debris 
is  thrown  into  the  blood,  and  cast  out  by  the  kidneys. 
Probably  owing  to  the  high  temperature,  the  form  assumed 
by  this  waste  is  the  soluble  urea.  Consequently  the 
specific  gravity  of  the  urine  is  high  ;  the  amount  of  urea 
present  being  twice  or  even  three  times  the  normal  amount 
(400  grains).  If  congestion  of  the  kidneys  occurs,  then  the 
output  is  interfered  with,  and  the  typhoid,  or  ursemic 
condition  is  set  up.  Its  semeia  have  been  given  before 
(p.  235),  and  need  not  be  recapitulated.  Looked  at  diagnos- 
tically,  that  is,  from  the  point  of  view  of  the  amount  of 
danger  in  which  the  patient  is  involved,  this  condition  is 
graver  the  older  the  subject,  and  the  greater  the  liability  to 
degenerative  change.  If  the  urine  be  albuminous,  and  still 
more  if  bloody,  there  is  congestion  of  the  kidneys ;  and  the 
danger  to  life  from  arrested  output  is  imminent.  The  tongue, 
too,  is  a  great  guide :  if  it  becomes  drier,  browner  with  fur, 
cracked   or  fissured,  and   like  a  brown   ball,  while  sordes 


THE  PATIENT  IN  HIS  BEDROOM.  237 

gather  on  the  teeth,  the  case  is  becoming  gloomier ;  if,  on 
the  other  hand,  the  tongue  become  moist,  and  there  is  a 
tendency  to  slied  the  brown  fur,  the  prospect  is  brightening. 
The  same  may  be  said  of  the  consciousness.  If  it  become  more 
and  more  clouded,  with  low  delirium,  the  typhoid,  or 
ursemic  condition  is  being  firmly  established,  with  death 
behind  it.  If  it  lighten  up  like  the  lifting  of  a  cloud,  hope 
beams  bej^ond  it.  The  therapeutic  management  of  this 
condition  will  in  certain  cases  exercise  a  profound  influence 
over  it,  as  in  the  typhoid  condition  of  specific  fevers  in  pre- 
viously healthy  persons;  while  in  old-standing  kidney 
mischief  our  power  is  more  limited.  Still  in  all  cases  we 
can  be  of  less  or  more  service,  and  should  try  what  can  be 
done,  first  to  lower  the  pyrexia,  upon  which  the  condition  of 
tissue- wasting  depends;  and  secondly  to  help  the  system  to 
cast  out  the  waste.  The  absence  of  these  evidences  where  the 
temperature,  v/hen  taken,  is  habitually  high,  tells  that  this 
is  really  due  to  neurosal  derangement  (see  p.  160).  If  the 
temperature  was  persistently  as  high  as  it  was  at  the  time  of 
observation,  the  effects  of  the  pyrexia  upon  the  tissues  would 
be  obvious. 

*  Picking  the  bedclothes'  is  a  phenomenon  justly  dreaded. 
It  tells  that  the  intellect  is  deeply  clouded  and  the  eyesight 
failing.  When  a  patient  with  fever  gets  to  the  length  of 
picking  the  bedclothes,  and  still  more  if  petechise  show 
themselves,  he  is  in  the  gravest  danger — in  '  the  valley  of 
the  shadow  of  death'  in  stern  reality.  The  death  of  Sir 
John  Falstaff  is  vividly  sketched  :  '  After  I  saw  him  fumble 
with  the  sheets,  and  play  with  flowers,  and  smile  upon  his 
fingers'  ends,  I  knew  there  was  but  one  way ;  for  his  nose 
was  as  sharp  as  a  pen,  and  a'  babbled  of  green  fields. 
"  How  now.  Sir  John  ?"  quoth  I.  "  What,  man  !  Be  of 
good  cheer."  So  a'  cried  out — "  God,  God,  God  !^^  three  or 
four  times.  Now  I,  to  comfort  him,  bid  him  a^  should  not 
think  of  God :  I  hoped  there  was  no  need  to  trouble  with 
any  such  thoughts  yet.     So  a'  bade  me  lay  m.ore  clothes 


PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 


on  his  feet.  I  put  my  hand  into  the  bed  and  felt  them, 
and  they  were  cold  as  any  stone  ;  then  I  felt  his  knees, 
and  they  were  cold  as  any  stone  ;  and  so  upward  and 
upward,  and  all  was  cold  as  any  stone.' 

There  are  other  forms  of  death,  as  the  statuesque  posi- 
tion with  the  fades  Hippocratica.  Here  the  nose  is 
pinched,  the  jaw  drops,  which  leaves  the  mouth  open  ;  the 
eyes  are  sunken  (the  cornese  being  dull,  having  lost  their 
transparency),  but  are  open  :  the  temples  are  hollow ;  the 
ears  shrunken  ;  while  the  skin  is  pale  and  leaden-looking, 
or  livid. 

Or  again,  the  peculiar  tout  ensemble  of  carbonic  acid 
poisoning,  the  terminal  phase  of  mitral  disease,  and  other 
maladies  involving  the  respiration.  The  desire  for  sleep 
is  intense;  and  the  patient  drops  off,  to  be  wakened  abruptly 
by  dyspnoea,  or  may  be  a  horrid  dream.  The  patient  fears 
to  sleep,  yet  is  unable  to  resist  the  overpowering  drowsi- 
ness and  drops  off  again — to  be  awakened  by  something 
horrid  ;  till  at  last  he  wakes  no  more. 

Then  there  is  the  Cheyne-Stokes  respiration  described  at 
p.  63. 

Then  the  patient  may  be  lying  flat  and  unconscious,  with 
the  stertorous  breathing  of  apoples}^,  or  the  hissing  breath- 
ing of  urfemia.  When  there  is  a  clot  in  the  brain  pressing 
upon  the  medulla  the  breathing  is  interfered  with ;  and 
when  this  occurs  it  is  clear  a  little  further  pressure  will 
abolish  the  respiration  altogether. 

Such,  then,  ure  some  of  the  final  scenes. 

There  are  some  other  matters  it  is  well  to  note,  as  a 
severe  abdominal  pain,  for  instance. 

If  the  patient  be  lying  flat,  with  the  knees  raised,  so  as 
to  relax  the  abdominal  muscles,  and  also  to  keep  ofl"  the 
weight  of  the  bedclothes,  then  there  is  peritoneal  inflam- 
mation present.  When  the  patient  is  rolling  about  in  bed, 
it  is  colic,  and  pressure  gives  relief;  which  is  attained  by 
pressing  the  belly  on  the  bed,  or  laying  the  hands  on  it.     If 


I 


THE  PA  TIENT  IN  HIS  BEDROOM.  239 

a  youDg  woman,  it  may  be  dysmenorrhoea.  In  lij^sterical 
peritonitis,  if  the  patient's  attention  be  drawn  elsewhere  the 
hand  may  be  pressed  upon  the  belly  without  attracting 
attention  ;  but  if  the  patient  be  cognizant,  the  slightest 
touch  is  agony  unspeakable. 

If  the  patient  be  tossing  about,  more  or  less  unconscious, 
with  blanched  features,  then  severe  hsemorrhage  is  present. 

When  the  patient  is  propped  up  with  laboured  breathing, 
this  '  orthopnoea'  tells  of  grave  cardiac  or  thoracic  mischief  ; 
aggravated  by  flatulence  or  other  cause  of  impediment  to 
the  descent  of  the  diaphragm. 

In  asthma  the  shoulders  are  fixed,  and  the  breathinof  is 
forced  and  voluntary. 

It  is  good  practice  to  walk  round  a  large  ward  and  study 
the  attitudes  of  the  patients  in  bed.  A  little  of  such 
systematic  observation  would  be  of  priceless  value  to  a 
young  man  about  to  enter  practice.  Tlie  wards  of  our  large 
parochial  infirmaries  are  admirably  adapted  for  such  obser- 
vations ;  and  a  few  visits  to  them  will  amply  repay  the 
time  so  spent.  Especially  valuable  is  such  observation  in 
the  matter  of  diseases  affecting  the  respiration.  In  phthisis 
and  pneumonia  there  is  the  hurried  respiration,  often  witli 
the  pink  flush  upon  the  cheek,  which  contrasts  with  the 
cord-like  muscles  of  the  neck,  and  the  abdominal  respiration 
of  emphysema,  with  or  without  bronchitis  ;  and  along  with 
these  the  heavy  breathing  of  cardiac  failure,  either  with  the 
purple  lips,  or  the  more  diflused  '  mitral  flush '  on  the  cheeks. 
It  is  well,  too,  to  familiarise  the  eye  with  the  postures  assumed 
in  nervous  affections  involving  more  or  less  paralysis.* 

When  the  patient  is  obviously  very  ill,  yet  is  in  an  arm- 
chair instead  of  being  in  bed,  he  is  usually  the  victim  of 
some  valvular,  or  other  cardiac  disease ;  or  some  other 
disease  which  will  not  allow  him  to  breathe  in  the  recum- 
bent posture. 

*  If  the  reader  conld  go  round  with  Dr.  Lloyd,  of  the  Lambeth 
Sick  Asylum,  he  would  profit  much  as  to  such  observations. 


240  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

When  a  patient  is  found  in  bed,  j'et  not  presenting  indi- 
cations of  severe  illness,  it  is  just  as  well  to  inquire  why  he 
is  in  bed ;  because  one  naturally  associates  being  in  bed 
with  serious  illness.  Probably  the  answer  will  be  that  the 
patient  went  to  bed  to  admit  of  complete  ph3'sical  examina- 
tion. This  is  one  outcome  of  the  present  exclusive 
admiration  for,  and  belief  in  physical  examination.  Now, 
to  me  at  least,  such  action  is  rather  misleading  than  other- 
wise; just  as  is  the  behaviour  of  some  nurses  who  strip  the 
patients  when  the  physician  is  going  round.  Personally  I 
am  not  in  the  habit  of  making  the  acquaintance  of  my 
patients  in  a  nude  torso,  and  such  act  '  throws  me  out.'  Of 
course,  for  those  physicians  who  do  study  their  patients  in 
the  nude,  such  action  is  right  and  proper ;  and  the  nurse  is 
taught  to  do  it  somewhere,  else  she  would  not  do  so.  The 
nearer  the  appearance  of  the  patients  to  that  of  other 
people,  the  less  the  difficulty  of  studying  them  with  the  eye. 
Consequently,  if  a  patient  is  not  so  ill  as  to  be  compelled  to 
stay  in  bed,  it  is  well  to  see  him  in  his  usual  clothes  first; 
and  then  send  him  to  bed,  if  desirable.  So  with  patients  in 
a  ward  ;  it  is  well  to  see  them  in  their  bed  attire  first,  and 
strip  them  when  the  time  comes.  The  diagnosis  is  not  to 
be  made  by  physical  examination ;  it  is  to  bo  completed  by 
it !  The  physical  examination  is  the  apex  of  the  diagnostic 
cone,  or  pyramid  :  not  its  base.  To  examine  for  the  disease 
before  examining  the  individual  in  whom  the  disease  exists 
is  like  an  inverted  pyramid  ;  ridiculous,  if  not  unsafe. 

The  observations  to  be  made  day  by  day  upon  the  patient 
in  bed  are  numerous,  often  minute.  The  condition  of  the 
tongue,  the  urine,  its  bulk  and  character,  often  the  stools 
should  be  examined  carefull}^  The  sleep,  the  appetite, 
often  the  cough,  and  the  patient's  feelings  should  be 
studiously  and  systematically  inquired  after.  Night  sweats 
should  never  escape  notice  ;  their  oncome,  their  departure, 
their  increase  or  decrease,  are  always  matters  of  importance. 
Any  new  attitude,  whether  involving  less  muscular  power, 


THE  PATIENT  IN  HIS  BEDROOM.  241 

or  more  strength,  should  be  recognised.  So  should  any 
clouding,  or  brightening  of  the  countenance.  If  the  patient 
be  in  clean  clothes,  and  bears  evidence  of  having  been 
washed,  this  is  always  a  good  sign  ;  unless  the  nurse  is  a 
headstrong  fool^  and  then  such  evidence  of  meddling  may 
mean  that  the  patient  is  to  be  all  the  worse  of  the  chill  and 
the  disturbance. 

Careful  observation  of  the  invalid  and  his  surroundings 
will  often  tell  much  in  itself,  as  well  as  give  direction  to  the 
inquiries.  If  the  medical  man  can  put  his  questions  aptlj^, 
it  shows  that  he  knows  what  he  is  about,  and  increases  the 
confidence  reposed  in  him  ;  which  last  adds  greatly  to  the 
likelihood  of  his  orders  being  obe3^ed.  And,  youthful  reader, 
let  me  tell  you  that  that  is  an  important  factor  in  diagnosis, 
i.e.,  of  diagnosis  in  its  prognostic  aspect. 

If  the  patient  be  surrounded  by  nurses  without  experi- 
ence, who  either  disobey  orders,  or  act  upon  their  own 
judgment,  the  prospects  of  the  patient  are  much  darker 
than  would  be  the  case  if  the  nurses  were  better  fitted  for 
their  places.  Often  something  has  been  done  that  is  pre- 
judicial to  the  patient;  and  the  doers  wish  to  conceal  their 
deed  from  the  doctor :  here  the  offenders  will  usually  lead 
off  with  some  loud  complaint  against  the  medicine,  or  the 
orders  ;  or  otherwise  '  get  the  first  word,'  and  lure  the  doctor 
away  from  suspecting  anything.  And  such  attitude  among 
ignorant  persons  is  at  once  suggestive  that  there  is  some- 
thing to  be  concealed.  Consequently  it  is  well,  in  giving 
an  opinion  as  to  the  probable  future  of  the  case,  often  to 
append  the  rider — '  Provided  the  orders  are  strictly  obeyed. 
If  they  are  deviated  from  in  any  way,  my  opinion  does  not 
hold  as  to  the  result.'  This  is  especially  called  for  where 
the  issue  is  doubtful,  and  the  opinion  hazarded  is  favour- 
able. The  very  persons  who  by  their  neglect  or  their 
meddlesomeness  falsify  the  opinion,  and  do  detriment  to  the 
patient's  prospects,  are  the  very  first  to  taunt  the  doctor 
with  having  made  a  mistake.     But  if  they  have  been  made 

16 


242  PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

clearly  to  understand  that  the  opinion  given  is  based  on 
the  presumption  that  the  orders  are  strictly  carried  out,  and 
they  are  not  carried  out,  or  something  has  been  done  that 
was  not  ordered,  then  the  doctor  can  rebut  their  charge  ; 
and  point  out  what  was  done,  if  it  come  to  his  knowledge, 
and  what  the  consequences  were. 

Two  classes  of  persons  make  untrustworthy  nurses :  (1) 
the  fussy,  meddlesome,  often  kindly  hearted,  well-meaning 
persons,  who  are  pretty  certain  to  perpetrate  '  sins  of  com- 
mission ;'  and  (2)  those  who  say  '  yes  '  to  everything,  and 
who  never  take  the  trouble  to  be  sure  that  they  have  caught 
your  meaning  correctly,  and  who  are  very  likely  to  commit 
*^sins  of  omission.'  In  a  doubtful  case  always  test  your 
nurses,  if  you  can,  before  you  hazard  your  opinion  ;  and 
when  you  indulge  in  a  favourable  opinion,  look  after  your 
nurses  watchfully;  else  your  prognosis  may  not  be  veritied 
from  avoidable  causes. 

Also,  and  this  is  said  in  all  humility,  please  remember 
that  the  treatment  often  exercises  a  profound  influence 
upon  the  case.  The  treatment  may  be  inefficient,  injudicious, 
or  injurious;  and  the  patient  is  sometimes  in  more  jeopardy 
from  his  treatment  than  his  malady  (and  this  is  apt  to  be 
true  of  the  employment  of  opium,  or  chloral,  ignorantly 
rather  than  recklessly). 

'  The  treatment  of  diseases  rightly  considered  is,  in  fact, 
part  of  their  pathology,'  wisely  said  Peter  Mere  Latham. 
There  may  be  a  lethal  factor  in  the  medicine-vial,  which 
does  not  reveal  itself  in  the  dead-house.  The  patient  may 
drop  into  a  grave  never  dug  for  him  by  nature.  It  is 
perilously  easy,  at  times,  to  verify  a  bad  prognosis. 

For  instance,  the  first  serious  case  which  came  under  my 
charge  after  gaining  a  diploma  was  that  of  a  severe  diarrhoea 
in  an  anaemic  woman.  She  was  evidently  very  gravely  ill, 
and  vigorous  measures,  opiates  and  astringents,  were  requi- 
site to  overcome  the  diarrhoea.  At  last  success  was  attained ; 
but  in  some  six-and-thirty  hours  after  the  cessation  of  the 


THE  PA  TIENT  IN  HIS  BEDROOM.  243 

diarrhoea,  urtemia  set  in  and  was  soon  fatal.  On  inquiry  of 
my  father,  who  had  been  away  a  few  days,  it  turned  oat 
that  the  woman  was  the  subject  of  well-marked  Bright's 
disease  with  albuminuria.  Of  course  it  was  unfortunate 
that  the  treatment  had  been  so  vigorous.  Left  alone,  pos- 
sibly the  case  would  have  pulled  round  by  the  efforts  of 
nature ;  as  it  was,  I  did  my  honest  best  to  thwart  her 
processes  with  an  untoward  result.  This  is  an  instance  in 
point  of  the  statement  made  above,  *  The  patient  is  some- 
times in  more  jeopardy  from  his  treatment  than  his  malady.' 
Had  I  been  in  possession  of  the  knowledge  that  chrom  i 
renal  disease  existed,  possibly  a  different  plan  of  treatment 
might  have  been  adopted,  with  a  less  unfortunate  result. 

Then  again  there  is  the  subjective  attitude  of  the  patient, 
a  matter  closel}''  allied  to  temperament,  spoken   of  before 
(p.  225).     If  the  patient  be  convinced  the  malady  will  be 
fatal,  a  very  poor  stand  is  made  usually;  and  he  quicklv 
succumbs,  if  the  malady  be  at  all  serious.     On  the  other 
hand,  there  is  the  effect  of  hopefulness,  or  strong  motive  to 
live.     Some  women    with    a   good    family    history   and    a 
strong  motive,  as  a  number  of  children  to  live  for,  will 
outride  almost  any  storm  of  illness  ;  and  only  go  down  when 
there  is  no  possibility  of  the  disease  being  thrown  off",  as 
cancer,  for  instance.     And  a  '  good  family  history  '  is  a  very 
important  matter  indeed  in  the  prognostic  aspect  of  diao-- 
nosis.     Some  years  ago  I  was   hastily  summoned  to  see 
a  case  where  the  typhoid  condition  was  present,  the  tempera- 
ture   103°,   and    the    urine    highly    albuminous;    and    the 
ordinary   medical    attendant   and   an    eminent    provincial 
physician  had  abandoned  all  hope.     Knowing  somethino-  of 
the   family  history   of   the    patient,  and  their  remarkable 
power  of  endurance  under  disease,  I  set  to  work  to  see  if 
there  was  any  local  explanation  of  the  general  condition. 
Nothing  could  be  found.     A  favourable  prognosis  was  given, 
and  the  patient  was  put  on  antipyretic  remedies  with  an 
excellent  result.     It  really  was  '  the  catamenial  week  of  the 

16—2 


k 


244         PHYSIOLOGICAL  FACTOR  LY  DIAGNOSIS. 

mensnal  cycle '  (p.  170),  a  matter  which  no  practitioner 
learns  except  when  a  case  actually  comes  before  him.  The 
lady  is  now  in  superb  health,  and  has  been  ever  since  she 
rallied  from  her  hairbreadth  escape. 

On  the  other  hand,  when  the  family  history  is  bad,  it  is 
well  to  be  very  guarded.  In  the  north  of  England  families 
in  this  respect  are  likened  to  wood ;  one  family  is  spoken 
of  as  'tough,'  another  as  'nashy'  (' crashy'),  i.e., 'brittle' : 
no  bad  comparison.  '  Tough  '  people  only  die  under  the 
onslaught  of  lethal  disease ;  while  *  brittle '  persons  snap 
readily  under  the  strain  of  disease.  If  by  any  possible 
means,  reader,  you  can  arrive  at  some  account  of  the 
fa.mily  history  in  a  grave  case^  do  so ;  the  information  may 
be  of  cardinal  value  to  you  in  helping  you  to  shape  your 
opinion. 

And  now  a  word  as  to  '  going  to  bed,'  or  *  remaining  in 
bed.'  When  ordei'ing  a  patient  to  keep  his  bed,  often 
urgent  remonstrances  are  put  forward  in  something  like 
this  form :  '  But  won't  it  weaken  him  to  stay  in  bed  V 
There  is  a  strong  impression  abroad  that  to  remain  in  bed 
is  weakening,  and  that  to  get  the  patient  up  a  while  is 
strengthening.  Probably  in  convalescence  after  acute  disease, 
as  a  specific  fever,  or  in  recovering  after  parturition — the 
two  conditions  of  acute  confinement  to  bed  with  which 
lay  persons  are  most  familiar — such  a  view  is  far  from 
incorrect.  But  as  applying  to  many  cases  of  debility  it  is 
absolutely  false.  Instead  of  gaining  a  little  strength  day 
by  day,  it  is  expended  in  attempts  to  get  up.  What  would 
be  thought  of  a  person  in  debt  to  a  certain  extent  if, 
instead  of  saving  a  sum  daily  till  the  amount  of  the  debt  is 
reached,  that  daily  amount  were  squandered  uselessly  ? 
Why,  the  debt  would  never  be  reduced!  So  it  is  in  some 
forms  of  illness.  The  patient  may  keep  his  bed  until  he  is 
strong  enough  to  get  up  with  profit,  which  day  will  come, 
sooner  or  later.  Hospital  patients,  as  a  rule,  are  as  anxious 
to  leave   their   beds   as  a  lunatic    to   get   away  from   an 


THE  PATIENT  IN  HIS  BEDROOM.  245 

asylum ;  the  exceptions  being  thoracic  cases  where  all  effort 
is  painful  from  shortness  of  breath — these  last  patients 
usually  are  only  too  tliankful  to  remain  at  rest.  Often,  too, 
especially  with  well-marked  anremia,  cases  will  not  improve 
while  going  about,  as  servants  trying  to  do  their  work,  etc., 
which  commence  to  improve  at  once  when  sent  to  bed. 
One  well-remembered  case  in  point  strikes  me.  When 
assistant-physician  to  the  West  London  Hospital,  a  case 
of  anaemia  in  a  young  nurse-girl  came  under  notice.  The 
girl  was  a  willing  servant,  and  her  mistress  was  much 
interested  in  her.  Fourteen  weary  months  she  was  under 
my  care,  taking  every  combination  of  tonic  and  chalybeate, 
without  improvement — barely  holding  her  ground.  She 
went  into  the  hospital  and  was  kept  in  bed,  when  she  com- 
menced to  improve  at  once  under  an  ordinary  iron  mixture. 
My  surprise  at  finding  her  in  the  hospital  was  increased  by 
the  fact  of  the  immediate  improvement  there  made,  when 
all  my  earnest  efforts  had  been  futile  so  long  as  she  was 
trying  to  work.  The  lesson  was  not  thrown  away,  and 
further  experience  has  only  graven  the  impression  deeper. 
When  you  have  a  case  of  debility  to  deal  with,  take  into 
your  calculation  the  matter  of  whether  the  patient  is  able, 
or  willing  to  go  to  bed  :  you  will  find  what  has  just  been 
said  to  hold  good  of  almost  every  case  of  debilit3^  To 
reduce  the  'body-expenditure'  below  the  'body-income' 
is  the  only  method  by  which  a  '  physiological  capital '  can 
be  acquired.  It  differs  no  whit  from  a  monetary  capital  in 
the  means  by  which  alone  it  can  be  secured. 

Such  matters  as  these  spoken  of  are  at  times  of  greater 
significance  than  the  revelations  of  the  stethoscope,  or  any 
hrvbit  de  diahle;  while  at  other  times  the  physical  examina- 
tion gives  the  clue  to  the  right  line  of  treatment  to  take, 
as  in  thoracic  embarrassment  from  pleuritic  effusion,  for 
instance.  At  times  it  is  the  diagnosis  of  the  individual, 
rather  than  the  nature  or  extent  of  his  malady,  which  is 
our  first  duty,  as  in  apex-consolidation,  for  instance  :  the 


246         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

matter  of  the  presence^  or  absence  of  moist  rales  being  what 
the  stethoscope  can  tell — and  it  only ;  and  then  if  they  are 
present,  it  is  the  patient  we  have  to  treat,  not  the  softening 
tubercle.  Still  the  matter  of  moist  rales  being  heard  will 
often  put  the  observer  on  his  guard ;  and  yet  here  again 
the  physiological  factor  of  the  temperature  is  required  to 
tell  whether  the  moist  rales  indicate  softening  tubercle,  or 
localized  bronchitis.  In  fact,  the  physical  signs  and  the 
physiological  disturbances  have  to  be  read  together  for  the 
correct  interpretation  of  any  complex  case.  The  men  of 
old  trusted  to  the  latter ;  because  they  knew  little  of  the 
former,  in  internal  disease.  Now  men  are  taught  physical 
signs  most  carefully,  almost  to  the  exclusion  of  the  other 
moiety.  Many  men  can  detect  minute  matters  connected 
with  physical  examination,  yet  cannot  put  their  data 
together  to  spell  anything.  It  is  like  the  game  of  *  Word- 
making^ — so  many  letters,  constituting  a  word,  are  mixed 
up  and  then  given  out ;  and  the  game  is  to  put  them  to- 
gether, so  as  to  find  out  the  word,  which  requires  time  and 
practice  as  well  as  pains  for  success. 

In  my  own  personal  experience  the  case  which  com- 
pletely puzzles  the  ordinary  newly  passed  man  is  that  of 
some  emphysema  with  bronchitis,  and  an  enlarged  right 
ventricle.  He  cannot  make  out  the  latter  by  percussion, 
on  account  of  the  emphysematous  condition  of  the  lung 
over  the  heart  (the  free  anterior  edge  of  the  lung  being 
usually  the  first  part  to  be  affected,  and  in  most  cases  it 
keeps  its  lead)  ;  and  so  misses  the  important  factor  of  the 
case  as  regards  its  treatment.  Usually  he  looks  helplessly 
at  the  patient,  unable  to  see  his  way.  Yet,  if  he  examined 
the  patient  physiologically,  that  is,  caused  him  to  make  an 
effort  and  noted  the  results,  the  nature  of  the  case  and  the 
line  to  take  would  be  revealed  to  him  like  the  unrolling  of 
a  scroll. 

Children. — There  are  some  points  to  be  noticed  about 
infants  of  great  importance,  of  more  importance  compara- 


THE  PATIENT  IN  HIS  BEDROOM.  247 

tively  than  in  adults,  because  the  infant  cannot  tell  you 
what  it  feels,  the  great  matter  ;  and  cries  so,  that  any  aus- 
cultation is,  visually,  simply  impossible.  When  a  child 
cries  without  ostensible  cause,  strip  it  naked ;  a  pin  in  its 
clothes  may  be  the  cause  of  its  discomfort.  If  it  has  got 
colic,  it  will  kick  its  little  legs  against  its  abdomen.  Often 
you  can  feel  the  hard  bowels  full  of  wind,  with  the  circular 
fibres  contracting  on  it.  Some  children  seem  to  feel  the 
vermicular  action  of  their  intestines,  without  any  marked 
morbid  condition  being  present ;  and  the  long-drawn  wail 
tells  of  the  long  pain,  like  the  cry  of  a  parturient  woman — 
— which  is  often  the  measure  of  the  length  of  a  uterine  pain. 
Then  there  is  the  hydrocephalic  hand,  described  by 
Kellie,  where  the  thumb  is  doubled  into  the  palm  and  the 
fingers  closed,  indeed  sometimes  clenched  over  it.  Often 
this  characteristic  '  hand'  will  put  the  observer  on  his  guard 
where  the  meningeal  mischief  is  masked  by  some  other 
more  obvious  morbid  condition,  as  bronchitis.  Few  men 
get  far  in  practice  without  stumbling  on,  or  over  may  be, 
this  complex  condition.  Then  the  actions  of  a  child  often 
tell  much.  If  a  male  child  pull  his  prepuce,  you  may  look 
out  for  a  vesical  calculus.  If  a  girl  rub  her  clothes  over 
her  person,  look  for  vaginitis.  If  a  child  pick  its  nose, 
there  is  usually  some  irritation  in  its  alimentary  canal, 
which  is  often  set  up  by  worms.  When  a  child  wets  the 
bed  at  night,  having  acquired  proper  control  of  the  sphinc- 
ters, spoken  of  by  nurses  as  '  giving  over  wetting  the  bed,' 
look  for  some  local  cause  of  irritation  in  the  pelvis,  which 
induces  the  bladder  centres  in  the  cord  to  relax  the 
sphincter;  commonly  it  will  be  found  to  be  'seat-worms,' 
or  an  anal  fissure,  etc.  When  a  child  is  abnormally  quiet, 
it  either  suffers  pain  when  moving^  as  a  broken  bone  or 
other  osteal  trouble  ;  or  it  has  no  breath  to  spare,  as  in 
thoracic  disease,  notably  rickets ;  or  it  has  lost  all  interest 
in  its  sports,  as  in  chronic  hydrocephalus.  Young  doctors 
are  rarely  credited  with  much  knowledge  about  children  ; 


24S         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

and  the  opinion  of  an  experienced  woman  is  usuall}'  pre- 
ferred. Nor  was  tliis  attitude  unjust  up  to  a  recent  period; 
nowadays,  every  thoughtful  student  attends  a  children's 
hospital  for  a  time,  and  learns  something  about  children. 
Children  require  a  keen  educated  eye  for  the  recognition  of 
their  troubles ;  and  the  education  is  a  gradual  process.  An 
acquaintance  with  one  case  usually  throws  a  flood  of  light 
upon  the  next  case  like  it  which  comes  under  notice. 
Some  time  ago  a  woman  brought  a  child  to  Victoria  Park 
Hospital  with  its  little  waistcoat  and  trousers  -  band 
fastened  by  tags  of  string,  like  what  is  seen  with  ascitic 
individuals.  The  application  of  the  hand  over  the  abdomen 
told  at  once  that  the  disease  causing  the  enlargeinent  of  the 
belly  was  an  amyloid  liver.  Having  a  great  deal  to  do,  no 
further  examination  was  made,  and  a  prescription  was 
written.  The  woman  demurred  to  this,  protesting  that  the 
examination  was  insufficient  to  determine  the  disease ;  so 
she  was  advised  to  take  him  over  to  my  colleague,  whom  I 
knew  would  make  a  most  careful  examination.  Looking  in 
upon  him  some  time  later,  he  was  found  with  the  child 
stripped,  having  satisfied  himself  thoroughly  as  to  the 
nature  of  the  disease.  Mentioning  my  opinion  of  it,  he 
said  it  was  correct.  I  had  spent  equal  pains  over  such 
cases  in  the  past,  a  matter  for  which  the  woman  gave  me 
no  credit;  as,  of  course,  she  also  could  know  nothing  about 
my  experience,  or  ni}'-  apparently  perfunctory  examination  ! 

The  following  remarks  are  taken  from  the  well-known, 
work  of  my  colleague,  Dr.  Eustace  Smith,  on  '  The  Wasting 
Diseases  of  Children/  and  are  worthy  of  being  'read,  marked, 
learned,  and  inwardly  digested.'  A  careful  perusal  of  the 
face  is  of  the  utmost  importance  :  b}^  it  we  may  not  only 
diagnose  pain,  but  even  its  seat.  Pain  in  the  head  is  indi- 
cated by  contraction  of  the  brows ;  in  the  chest  by  a 
sharpening  of  the  nostrils ;  in  the  bellj''  by  a  drawing  of  the 
upper  lip. 

Enlargement  of  the  belly  is  usually  attributed  to  mesen- 


THE  PATIENT  IN  HIS  BEDROOM.  249 

teric  disease ;  yet  this  is  very  rare  in  children  under  three 
years  of  age.  Percussion  will  quickly  tell  if  the  enlarge- 
ment be  due  to  flatulent  distension ;  which  is  usually  owing 
to  bad  feeding.  Mesenteric  disease  is  not  uniform ;  and 
when  the  swelling  of  the  belly  is  uniform,  and  no  tumour 
can  be  felt,  glandular  enlargement  is  not  the  cause  thereof: 
whatever  is.  If  the  liver  is  enlarged,  its  edge  can  usually 
be  felt. 

The  colour  of  the  face  is  suggestive.  Lividity  indicates  a 
weak  circulation,  or  an  embarrassed  respiration;  a  waxy 
tint  indicates  syphilis  ;  while  an  earthy  hue  is  seen  in  many 
cases  of  bowel  complaint.  Coolness  and  pallor  of  the  face, 
with  lividity  of  the  eyelids,  the  lower  parts  of  the  whites  of 
the  eyes  being  exposed,  with  depression  of  the  fontanelles, 
mean  exhaustion,  indicating  restoratives.  '  Snuffles '  tell 
of  syphilis;  and  so  do  chaps  and  fissures  of  the  mouth, 
or  anus. 

If  the  breathing  is  rapid,  the  chest  should  be  exposed, 
and  the  unequal  movements  of  the  two  sides  of  the  thorax 
are  significant  of  a  lesion  on  the  less-acting  side.  If  the 
accessory  muscles  of  respiration  are  active,  there  is  probably 
some  abdominal  mischief  present ;  if  the  respiration  be  dis- 
tinctly abdominal,  there  is  probably  some  thoracic  disease 
existent. 

The  cry  of  the  infant  varies  much  in  character.  In 
cerebral  alfections  it  is  sharp,  short,  and  sudden.  In 
abdominal  pain  it  is  prolonged.  In  inflammatory  disease  of 
the  lungs,  and  in  rickets,  the  child  is  usually  quiet,  and 
unwilliug  to  cry  on  account  of  the  action  interfering  with 
the  respiration.  In  inflammatory  aff'ections  of  the  larynx 
it  is  hoarse,  and  may  be  whispering.  In  inherited  syphilis 
it  is  high-pitched  and  hoarse.  The  cry  of  a  syphilitic  child 
is  so  characteristic,  that  a  story  is  told  of  an  eminent  physician, 
a  very  acute  observer,  detecting  the  syphilitic  element  in  a 
puzzling  case,  before  he  ever  saw  the  child;  ouly  hearing  it 
cjy  in  the  next  room.    It  is  well,  too,  to  learn  to  discriminate 


250         PHYSIOLOGICAL  FACTOR  IN  DIAGNOSIS. 

the  steady  how],  or  ano^ry  screech  of  temper  from  the 
cry  of  real  suffering ;  which  a  little  attention  will  suffice 
to  do. 

Then  reflex  excitability  is  destroyed  by  cachexia.  If  in  a 
healthy  child  the  finger-nail  be  drawn  along  the  upper  two- 
thirds  of  the  inner  aspect  of  the  thigh,  the  testicle  of  that 
side  is  drawn  close  to  the  abdominal  ring  by  the  action  of 
the  cremaster  muscle.  In  a  cachetic  child  this  result  does 
not  follow.  Any  sudden  weakening  of  a  healthy  child  is 
accompanied  by  reflex  movements,  as  convulsions.  '  When 
debility  is  produced  more  slowly  the  same  result  does  not 
follow,  and  the  excitability  of  the  nervous  system,  instead 
of  being  exalted,  is  more  or  less  qompletely  destroyed.' 

Where  there  is  great  emaciation  with  a  furfuraceous  skin 
there  is  certainly  neglect;  and  often  resort  to  narcotics, 
especially  in  manufacturing  districts  where  the  mothers 
work  from  home. 

In  examining  a  child  it  is  well  to  go  over  the  examination 
carefully  stej')  by  step,  so  that  the  mother  or  nurse  can 
follow  it.  A  rapid  comprehensive  glance  may  take  in  all 
the  points  ;  but  that  is  not  enough.  The  onlookers  have  to 
be  convinced  that  the  observations  are  actually  made.  It 
is  like  making  an  examination  before  students  ;  every  detail 
must  be  taken  deliberately  in  its  turn.  The  rapid  glance  is 
only  credited  with  utility  where  the  experience  of  the 
practitioner  is  obvious  from  his  age;  and  the  onlookers  have 
confidence  in  him.  Indeed,  with  many  persons  a  careful 
pointing  out  of  obvious  facts  impresses  them  very  favourably. 
But  practical  psychology  is  no  part  of  my  design.  Young 
practitioners  should  not  only  possess  the  knowledge ;  but 
they  should  be  able  to  demonstrate  to  the  patients  and  their 
friends,  that  the  knowledge  is  existent ;  else  it  is  to  be 
feared  they  will  not  always  get  credit  for  its  possession  ; 
and  this  is  especially  true  when  children  are  being  dealt 
with. 

When   the  patient  is  encountered  in  the  sick-room  tliQ 


THE  PATIENT  IN  HIS  BEDROOM.  251 

medical  man  requires  quickness  of  observation,  wlietlier 
natural  or  acquired,  even  more  than  at  other  times ;  and 
the  habit  of  careful  intelligent  observation  is  invaluable  in 
the  sudden  emergencies  which,  from  time  to  time,  present 
themselves  in  the  sick  room ;  over  and  beyond  obstetric 
emergencies,  which  last  put  the  finishing  touch  to  the  medical 
man's  education.  '  Education  is  not  mere  information ' :  it 
implies  not  only  the  possession  of  the  information ;  but  the 
capacity  to  wield  it  promptly.  Education  goes  on  during 
the  whole  of  life ;  and  of  all  men  the  medical  man  is  a 
student.  Still,  it  must  be  admitted  there  do  exist  men 
who  regard  their  education  as  complete  when  the  final 
examination  is  past,  and  who  close  their  minds  to  the 
entrance  of  further  knowledge  ;  like  the  young  lady  who 
has  completed  her  term  at  a  '  finishing  school.-'  As  they 
are  not  likely  to  peruse  this  work,  this  remark  will  not 
wound  their  feelings.  The  man  who  ceases  to  make  onward 
progress  will  soon  be  left  behind  by  the  crowd  who  do  push 
on ;  of  that  this  class  may  rest  assured. 


CHAPTER  XIII. 

CONCLUSION. 

When  the  practitioner  has  made  a  careful  estimate  of  the 
individual  before  him,  by  the  light  of  what  has  been  written 
here,  it  will  be  well  to  examine  into  the  nature  and  extent 
of  his  malady  by  careful  physical  examination  ;  i.e.,  if  it  is 
a  malady  which  reveals  itself  by  physical  signs.  This  he 
is  enabled  to  do  by  his  hospital  education,  and  tlie  many 
excellent  works  on  '  Physical  Examination '  now  published. 

But  diagnostically,  prognostically,  and,  still  more  even, 
therapeutically^  it  is  well  to  appraise  the  individual  before 
making  an  estimate  of  the  disease.  Both  must  be  alike 
calculated. 

It  is  not  successful  practice  to  proceed  at  once  to  the 
latter,  and  omit  the  former.  The  latter  belongs  to  strictly 
medical-school  teaching ;  the  former  the  practitioner  must, 
in  the  main,  teach  himself.  To  this  end  this  little  work  will 
probably  be  helpful.     At  least,  such  is  the  writer's  hope. 

Nor  must  the  reader  run  away  with  the  impression  that 
this  work  is  the  preaching  of  a  crusade  against  physical 
examination  !  Let  that  be  learnt  thoroughly  by  all  means. 
It  is  the  disproportionate  attention  paid  to  it  as  compared 
to  other  matters  of  diagnosis,  the  inordinate  value  of  the 
estimate  of  the  disease  as  compared  to  the  individual — his 
diathesis,  temperament,  nutrition,  etc.,  which  obtains  in  the 
present  scheme  of  medical  education,  against  which  a  pro- 
test is  here  entered.     It  is  not  that  the  student  be  taught 


CONCLUSION.  253 

less;  but  that  he  be  taught  more,  really,  which  is  here 
urged.  Let  the  physical  examination  and  the  physiological 
factor  in  the  case  stand  more  upon  level  ground,  or  equal 
terms,  than  they  do  at  present.  The  former  without  the 
latter,  as  much  as  the  latter  without  the  former,  maj?-  be 
likened  to  a  cart  with  only  one  wheel. 

And  now  the  time  has  arrived  when  the  writer  as  a 
medical  author  must  take  leave  of  his  readers.  He  has 
written  voluminously ;  not  in  vain,  if  the  sale  of  his  works 
can  be  trusted  as  any  valid  evidence  of  the  favour  they  have 
met  with.  The  encouragement  so  given  him  has  incited 
him  to  go  on ;  despite  the  impression  abroad  that  much 
writing  means  little  practice.  His  books  have  brought  him 
practice,  each  its  modicum.  Nevertheless,  for  the  future 
his  time  must  be  devoted  to  the  revision  and  enlargement 
of  already  existent  works,  in  the  new  editions  their  sales 
demand.  It  is  indeed  a  pleasure  to  write  for  appreciative 
readers  ;  that  pleasure  he  has  tasted  liberally.     Vale  ! 


INDEX. 

PAGE 

PAGE 

Abdomen 

.     30 

Cough,  whooping .        .        . 

69 

Abdominal  respiration  . 

.     59 

Cramps          .        .        .        . 

193 

Accelerated  action  of  heart 

91 

Curves,  temperature 

172 

Act  of  urination    . 

.   144 

Albuminuria 

.  133 

Damp  hand  .        .        .        . 

32 

„           true  and  false 

.  138 

Deep  respiration   . 

58 

Amenorrhoea 

.   151 

Delayed  pulse 

79 

Anorexia 

.  109 

Diabetes        -        .        ,        . 

142 

Appearance,  external     . 

.       6 

Diarrhoea      .        .        .        . 

119 

„             general 

.       8 

Diathesis,  bilious  . 

11 

Appetite 

.  105 

„        gouty    . 

9 

„        importance  of 

.  223 

„        lymphatic     . 

11 

Arcus  senilis 

.     22 

„        nervous 

10 

Arrested  action  of  heart 

.     90 

„        strumous 

9 

Artery,  temporal  . 

.     37 

Digestion  on  pulse,  effects  of 

90 

Asthma,  cardiac    . 

.     62 

Digestion,  secondary     . 

112 

Dilatation,  pulse  in 

85 

Bilious  diathesis   . 

.     11 

Disorders  of  sensations 

196 

Bounding  pulse     . 

.     79 

Disturbances,  trophic    . 

195 

Bowels  to  brain,  relations  of 

121 

Dysmenorrhoea 

154 

.,        irritable     . 

.   122 

Dyspepsia     .        .        .        . 

111 

Breath,  shortness  of 

.  203 

Dysphagia     .        .        .        . 

101 

Bulimia 

.   110 

Dyspnoea       .        .        .        . 

65 

Bulk  of  urine 

.   125 

„        nocturnal 

61 

Cachexise       .    _    . 

13 

Ears 

28 

Calomel  and  opium 

45 

Effect  of  effort  on  respiration 

60 

Cardiac  asthma     . 

62 

„      of  digestion  on  pulse  . 

90 

Catamenia,  history  of    .       -J 

,  149 

Eye 

22 

Cerebral  vomiting 

104 

Eye-brow       .        .        .        . 

21 

Character  of  urine 

127 

Eye-lashes     .        .        .        . 

21 

Children 

245 

Eye-lids         .        .        .        . 

21 

Chin      .... 

28 

Expressions  .         .        .        . 

14 

Cleaning  of  tongue 

44 

External  appearances   . 

3 

Clothes  .... 

34 

Clubbed  fingers     . 

32 

Face,  vascularity  of 

36 

Colic      .... 

114 

False  albuminuria 

138 

Collapse 

164 

Family  history 

3 

Constipation 

117 

Fast  pulse     .... 

76 

reflex 

121 

Fatty  heart,  pulse  in     . 

86 

Convulsions  . 

192 

Fauces  

53 

Cough    .... 

67 

Feet 

34 

INDEX. 

255 

I'Aci; 

PAGE 

Flatulence      .        .        .112, 

118 

^lotor  power  lessened  . 

.  183 

Forehead       .        .        .        . 

91 

^Mouth,  roof  of 

.     53 

Gait 

34 

Nails 

.     33 

„    nervous  .        . 
Gastralgia     .        .         .         . 

190 
115 

Nausea .         .        .        . 
Neck      .        .         .        . 

.  105 

Glycosuria    .        .        .        . 
Gouty  diathesis     . 

139 
9 

Nervous  diathesis 
„       gait         . 

Neurosal  palpitation     . 
„        temperature  . 

.     10 
190 

Gouty  heart,  pulse  in    . 
Gouty  teeth  .        .        .        . 
Gums 

84 
26 
26 

.  208 
.  160 

Nocturnal  dyspnoea   -  . 

.     61 

Hfemoglobuline     . 

TT       ■ 

144 

Nose 

. 

.     25 

-Hair 

Hand 

18 
31 

Observation  of  patients  i 

nbed  238 

„     damp    .         .        .        . 

32 

Opiu 

m  and  calomel 

.     45 

„    strumous 

31 

Hard  pulse    .         .        .        . 

79 

Pain 

. 

.  209 

Headache      .         .        .        . 

213 

Palpitation    . 

.  206 

Heart,  accelerated  action  of . 

91 

)) 

neurosal 

,  208 

„      arrested  action  of 

90 

Paraplegia     . 

.  189 

„      pulse  in  fatty    . 

86 

Pharynx 

.     53 

„      pulse  in  gouty  . 

84 

Position  and  respiratior 

1        .     70 

Hemiplegia  .         .        .        . 

187 

Power,  lessened  motor 

.  183 

Hiccough 

69 

Pruritus  ani  . 

.  116 

History  of  catamenia    . 

4 

Pulst 

.     73 

„          family. 

3 

!) 

bounding 

.     79 

„          of  individual 

3 

J5 

delayed 

.     79 

How  to  feel  the  pulse   . 

74 

11 

dicrotic 

.     80 

Hues  of  skin 

16 

11 

digestion,  effects  c 

f  on      90 

Hunger 

108 

11 

fast 

.     76 

Hypertrophy,  pulse  in  . 

84 

11 

hard 

.     79 

11 

how  to  feel    . 

.     74 

Importance  of  sleep 

223 

11 

in  dilatation 

.     85 

Increase  of  sexual  power 

48 

)) 

in  fatty  heart 

.     86 

Indications  of  tongue    . 

42 

11 

in  hypertrophy 

.      84 

Individual,  history  of    . 

3 

11 

in  gouty  heart 

.     84 

Intermittency  of  pulse  . 

88 

11 

in  valvular  lesion 

3         .     81 

Irregularity  of  pulse     . 

87 

11 

intermittency  of 

.     88 

Irritable  bowels    . 

122 

11 

irregularity  of 

.     87 

„         tongue    . 

47 

11 

paradoxus    . 

.     80 

11 

rate  of  respiratioi 

ito    .     57 

Late  rigidity . 

188 

11 

slack     . 

.     78 

Lips       .... 

25 

11 

slow 

.    77 

Leucorrhoea  . 

156 

11 

tight      . 

.    78 

Lymphatic  diathesis     . 

11 

11 

vuiequal 

.     91 

11 

visible  . 

.     79 

Manner. 

35 

wiry      . 

.     80 

Matrimony    . 

5 

Pulsation,  venous 

.     92 

]\Iaturity 

4 

Pyrexia . 

.   165 

Menorrhagia . 

153 

Pyrosis  . 

.  114 

256. 

INDEX. 

PACE 

PAr.r 

Haw  tongue  . 

.     51 

Tongue. 

39,  185 

Eeflex  constipation 

.  121 

Tongue,  cleansing  of     . 

.     44 

Keflex  vomiting    . 

.     .    .  104 

,,        indications  from 

.     42 

llelations  of  bowels  to 

Drain    121 

„*        irritable  . 

.     47 

Ptigidity,  late 

.   188 

„        raw. 

.     51 

Tonsils  .... 

.     53 

Sneezing 

.     70 

Troijhic  disturbances    . 

.   195 

Spasms  . 

.  193 

True  albuminuria . 

.  138 

Stokes'  respiration 

.     63 

Typhoid  condition 

.  235 

Stools    . 

.   119 

Strabismus    . 

.  184 

Unequal  pulse 

.     91 

Stridor  . 

.  .  65 

Urates  .... 

.  130 

Strumous  diathesis 

.       9 

Urea      .... 

.  133 

hand    . 

..     31 

Urination,  act  of  . 

.   144 

Syncope 

.  205 

Urine,  bulk  of 

.   125 

Syphilitic  teeth     . 

.     27 

„        character  of 

.  127 

„       sediments  in 

.  12S 

Teeth     . 

.     26 

Uvula    .... 

.     53 

„    gouty 

.     26 

.,     syphilitic 

.     27 

Valvular  lesions,  pulse  in 

.     81 

Temperament 

.  225 

Venous  pulsation  . 

.     92 

Temperature  curves 

.  172 

Vertigo  .... 

.  114 

Temperature,  neurosal 

.   160 

Visible  pulse 

.     79 

Temporal  artery    . 

.     37 

Voice     . 

.     72 

Tenderness    . 

.  2]8 

Vomiting 

.   102 

Tenesmus 

.  116 

„   •     cerebral 

.  104 

Thermometry 

.  177 

„        reflex     . 

.  104 

Thorax  .        .        .        . 

.     30 

Tight  pulse   . 

.     78 

Wiry  pulse    . 

.     80 

THE   END. 


Baillvre,  Tindull  d-  Cox,  SKc.m  Priiiitrs,  20,  King  William  Street,  Strand. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

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This  book  is  DUE  on  the  last  date  stamped  below. 


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